Acad Psychiatry DOI 10.1007/s40596-015-0456-0
EMPIRICAL REPORT
The Hidden Ethics Curriculum in Two Canadian Psychiatry Residency Programs: A Qualitative Study Mona Gupta 1 & Cynthia Forlini 2 & Keith Lenton 3 & Raquel Duchen 4 & Lynne Lohfeld 5
Received: 7 September 2014 / Accepted: 22 October 2015 # Academic Psychiatry 2015
Abstract Objective The authors describe the hidden ethics curriculum in two postgraduate psychiatry programs. Methods Researchers investigated the formal, informal, and hidden ethics curricula at two demographically different postgraduate psychiatry programs in Canada. Using a case study design, they compared three sources: individual interviews with residents and with faculty and a semi-structured review of program documents. They identified the formal, informal, and hidden curricula at each program for six ethics topics and grouped the topics under two thematic areas. They tested the applicability of the themes against the specific examples under each topic. Results pertaining to one of the themes and its three topics are reported here. Results Divergences occurred between the curricula for each topic. The nature of these divergences differed according to local program characteristics. Yet, in both programs, choices for action in ethically challenging situations were mediated by a minimum standard of ethics that led individuals to avoid trouble even if this meant their behavior fell short of the accepted ideal.
* Mona Gupta [email protected] 1
l’Université de Montréal, Montréal, QC, Canada
2
The University of Queensland Centre for Clinical Research, St Lucia, QLD, Australia
3
McGill University, Montréal, QC, Canada
4
Institute for Clinical Evaluative Sciences, Toronto, ON, Canada
5
McMaster University, Hamilton, ON, Canada
Conclusions Effective ethics education in postgraduate psychiatry training will require addressing the hidden curriculum. In addition to profession-wide efforts to articulate high-level values, program-specific action on locally relevant issues constitutes a necessary mechanism for handling the impact of the hidden curriculum.
Keywords Psychiatry residents . Ethics . Professional development
Although ethics education has long been a component of undergraduate medical education, the Royal College of Physicians and Surgeons of Canada now requires that it be provided within all postgraduate training programs as well [1] and has made substantial efforts toward developing an ethics curriculum for residency training [2]. Several authors have pointed out that formal ethics education operates in parallel with informal and hidden ethics curricula, the latter being more subtle, pervasive, and influential in shaping the learning environment and student behavior [3, 4]. The informal curriculum consists of unscripted, interpersonal forms of teaching and learning that take place between faculty and students, whereas the hidden curriculum refers to influences at organizational and cultural levels that inform the learning process [5] and can undermine the formal content. Previous analyses of the impact of the hidden curriculum have suggested that, if unaddressed, negative values and behaviors inculcated through it can lead to ethical erosion instead of ethical development as training progresses [6–9]. Thus, the Future of Medical Education Postgraduate Project report [10], funded by Health Canada, recommends that postgraduate education organizations and faculties of medicine attempt to address the counterproductive elements of the hidden curriculum.
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Addressing the impact of the hidden curriculum in postgraduate education requires knowledge of how it operates in that particular context. However, our understanding of it is based primarily on studies in undergraduate medical programs (e.g., [11–14]). Therefore, we decided to investigate the formal, informal, and hidden ethics curricula at two postgraduate training programs in the same specialty. Recently, Van Deven and colleagues [15] adopted a similar approach in radiology. We chose to focus on psychiatry training because of our participation and professional experience in postgraduate education in psychiatry, which we believed would help us better understand the views and experiences of our study participants. We aimed to compare and contrast the content of the formal, informal, and hidden ethics curricula in two demographically different postgraduate psychiatry programs (hereafter program 1 and program 2) and to explain potential divergences between the three curricula. To achieve these aims, we compared findings from three sources of data: individual interviews with residents and with faculty and relevant documents from each program. This in-depth qualitative study serves as a useful empirical complement to the existing conceptual work on the hidden curriculum in ethics, which lays out, on theoretical grounds, the high-level values embedded within the culture of the medical profession that motivate the hidden curriculum [16–19].
Methods Study Design and Setting We decided to use qualitative case study as our overall research design because it is appropriate when (1) the phenomenon of interest is ongoing rather than historical and cannot be separated from the context in which it occurs and (2) researchers want to answer “how” and “why” questions in addition to determining what is happening in the situation under study [20, 21]. Specifically, we conducted an instrumental case study because we were using the cases (the programs) to gain insight into the issue of the potential divergences between the formal, informal, and hidden ethics curricula rather than evaluating the specific programs themselves. We also decided to conduct a multiple- rather than single-case study because we wanted to gain in-depth understanding of the issue by comparing data from two very different contexts that were likely to shape study participants’ experiences and views on ethics training in their programs [22–24]. Although all psychiatry postgraduate programs in Canada must adhere to the same nationally mandated formal curriculum in terms of specific rotations and their content, we intentionally chose two programs that contrasted in location and size to facilitate our comparison.
Sources and Data Collection A hallmark of the qualitative case study design is collecting and comparing findings from multiple sources of data (triangulation) to gain a deep understanding of the topic under study [25, 26]. For each program we collected data from three sources to achieve triangulation: (1) documents from the program, hospital or faculty (e.g., ethics curriculum documents, ethics policy papers, and departmental mission statements); (2) key informants (i.e., faculty and residents who, because of their roles in their programs, had insider knowledge about key ethical issues); and (3) resident volunteers. To preserve confidentiality, we will not name the specific roles of potential key informants. Given the potentially sensitive subject matter of the interviews, the study team took particular care to recruit participants using confidential means (e.g., by individual mailings rather than group announcements) and to offer to conduct interviews away from their base hospital if participants wished. Focus group participants additionally agreed to confidentiality of matters discussed within the group. The study received formal research ethics board approval at both locations. Each participant gave informed consent before participating in the study. A semi-structured document review enabled us to describe the formal ethics curriculum for each program, develop questions for the individual interviews, and identify potential key informants. This was an information-gathering step only, to which we did not apply a specific theoretical framework. We developed the interview guides through team discussion and a review of the extant literature. This process enabled us to develop open-ended questions, whereas our document review enabled us to develop program-appropriate probes to these general questions. We recruited 19 key informants from program 1 (47 % of whom were residents) and 5 from program 2 (20 % of whom were residents). Because we also interviewed residents in the second phase of interviewing, we were not concerned that the key informant group had only one resident in program 2. One potential program 1 key informant declined to participate on the grounds that it was “too risky”; we were not able to obtain any further information about this decision. An interviewer at each site, unknown to the participants and working outside the program, conducted a semi-structured interview following the interview guide with each key informant. We then invited participation from the entire resident body at each site. We recruited 16 resident volunteers in program 1 (out of the approximately 100 remaining residents not identified as potential key informants) and 8 in program 2 (out of approximately 14). These semistructured interviews were conducted by the project’s resident co-investigators, who were also unknown to the interviewees. The resident co-investigators acted as interviewers for the resident interviews at their counterpart program as
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part of the training opportunity offered by the research project. All interviewers participated in a formal training session with an experienced qualitative researcher. The training involved a review and discussion of interviewing methods and skills, practice interviews using the draft interview guide to identify potential challenges that could arise in interviewing, and feedback on each interviewer’s interviewing technique. For logistical reasons, the interviewer for the program 2 key informants participated in-training sessions via telephone. The training ensured consistency in the interviewers’ techniques and interview quality. The individual interviews with both key informants and residents asked participants to reflect on what ethics is; how it is taught, learned, and evaluated; how it manifests in behavior and character; how the programs communicate and embody ethics to faculty and trainees; and the ethical issues that were of concern within the programs. Each interview was audio-taped and transcribed, except for one in which the participant declined to be taped but agreed to have statements recorded via field notes taken by the interviewer. The interviewers reviewed the transcripts of their interviews to correct any transcription errors. The researchers sent the corrected transcript and a summary of key points to each participant for review, corrections, or withdrawals. We then identified a small number of tentative, emerging, thematic areas for the two programs. We used a focus group discussion at each site with resident volunteers (recruited via open invitation) to confirm and refine, or disconfirm, these themes.
they self-identify as students versus professionals, influence how they respond to ethically difficult situations where there are curricular divergences. The two themes subsumed six ethical issues or topics (there were three topics under each theme). We examined the plausibility and applicability of two themes through extensive review and testing against the interview data. That is, for each instance in which a participant spoke about one of the topics, we tried to determine whether the theme applied to what was described. In this paper, we report on the first theme and its three topics.
Results Three topics that elicited ethical concern for the participants in our study included (1) interactions with the pharmaceutical industry, (2) dealing with colleagues’ ethical lapses, and (3) evaluating residents’ performance, especially when addressing professionalism (Table 1). These three topics were noted and/ or elaborated upon in detail by key informants and residents alike. In the following section, we will identify the overall message transmitted via the formal, informal, and hidden curricula for each topic, indicating the divergences between curricula where they arose. We will support these findings through direct quotations from 17 of our 48 participants (35 %). Our analysis points to the overarching theme of a minimum standard of ethics, which explains curricular divergence and shapes the options for action in ethically challenging situations.
Data Coding and Analysis
Explaining Curricular Divergence: The Minimum Standard of Ethics
Our analysis followed methods described by various case study researchers whose guidelines are an accepted part of the qualitative research literature [22, 23, 27]. Our data organization and analytic processes involved two or more analysts at all times. First, we organized the data descriptively under the headings of formal, informal, and hidden curriculum using a qualitative data management software program (Nvivo7). We identified various ethics topics in each curriculum, linked them to specific examples in the interviews, and described the formal, informal, and hidden message about that topic. We then searched for convergences and divergences between the three curricula, as well as similarities and differences between the two programs. We identified six topics of concern in both programs for which there were divergences between the curricula. Through ongoing, iterative discussion among the analysts, we then identified two themes concerning curricular divergence. The two themes were: (1) for certain ethically challenging issues, divergences between the formal, informal and hidden ethics curricula can be explained and resolved via the operation of a “minimum standard of ethics”; and (2) residents’ identities in their training years, specifically whether
Residents witnessed divergences between what they were taught formally, what they learned informally through supervision and other clinical interactions, and what they absorbed through the hidden curriculum. Why do these divergences occur, and how do individual residents determine the correct course of action in the face of these divergences in ethically challenging situations? Participants identified a basic level of behavior that was considered acceptable in any given situation—a minimum standard of ethics. To fall below this threshold was unethical, whereas to go beyond it was ideal. Of these two options, it was often easier for the participants to identify what fell below the minimum standard. As one key informant from program 2 noted, “What constitutes professionalism in our discipline, in our profession, is more obvious when there is an egregious breach than when there is a positive professionalism displayed. So, it’s only when somebody falls below what seems to be the general standard that this comes to light.” By knowing what is unethical, that is, what one should not do, residents could identify ethically acceptable alternatives. The most laudable course of action represented what a good or ideal physician would do. Awareness of the ideal, however,
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Divergences in the messages arising from formal, informal and hidden curricula in postgraduate psychiatry training at program 1 and program 2
Topics of ethical concern
Message from the formal curriculum
Message from the informal curriculum
Message from the hidden curriculum
1. Interactions with pharmaceutical companies and representatives
Do not interact with industry. (1)
Interact if you wish, but don’t do anything excessive. (1)
There is no consensus about what is unethical. (1, 2) You have more liberty if you are a researcher. (1)
Getting involved is optional. (1, 2)
Whatever you do, don’t get in trouble. This might mean you do nothing. (1>2)*
No message (1, 2)
Your personal relationship with a supervisor and your personality will influence your evaluations. (1, 2)
2. Dealing with colleagues’ ethical lapses
3. Formal evaluations of residents’ performance, particularly their professionalism
Everyone should make his/her own decision about whether or not to interact. (2) Report the problem via the chain of command or go directly to the person to address it with him/her (1,2) Evaluations should be conducted according to objective standards; and should adhere to the CANMEDs roles. (1, 2)
* This message was emphasized to a greater extent in program 1 than in program 2
was insufficient to guide action due to constraints such as respect for, or fear of, hierarchy or lack of time. For each of the three ethics topics shown in Table 1, participants described a course of action that allows the physician to meet the ethical obligations of the “good enough physician,” which represented a compromise between the ideal and the unethical. This minimum standard sustains divergence between what is formally taught and what is actually done day to day in the programs (Table 2). a) Interactions with the Pharmaceutical Industry How one should interact with the pharmaceutical industry was a major ethical issue identified by respondents at both sites. Program 1 has a written policy discussing such interactions, which made up part of the formal ethics curriculum for this topic [28]. The major concern discussed in the document was avoiding “perceived and real conflict(s) of interest in the complex Table 2
relationship between physicians and the pharmaceutical industry” (p. 2). In program 1, being in or even being perceived to be in a conflict of interest was considered below the minimum standard for ethical behavior, which one key informant there described as: … working very closely with the company as a consultant or a member of an advisory board, and then writing guidelines that have to do with the products of those companies. Or giving talks in inappropriate venues where the talk is promotional, and where the meal in one of the best restaurants in “…” clearly is more of an inducement than the talk itself. Situations where faculty members allow representatives of industry to have kind of inappropriate access to the residents and medical students. At the same time, seeing that faculty members interacted with industry showed that some interaction was permissible.
Influence of the minimum standard on the choice of action in the ethically challenging situations at each program
Ideal
Minimum standard
How physicians should interact with pharmaceutical companies
How physicians should deal with a colleague’s ethical lapse
How faculty should give feedback to residents about professionalism
No contact with pharma to avoid real or perceived COI (1) No consensus (2) Don’t do anything excessivea (1)
Address issues directly with the individual (1, 2)
Feedback should be comprehensive, constructive, and personal (1, 2)
Option 1b – follow the chain of command (1, 2) Option 2b – say nothing (1, 2) No message
Give an objective assessment, even if trivial, without offending (1, 2)
Follow individual values (2) Below minimum standard
Participating in activities that are promotional or non-scientific (1) No consensus (2)
Allowing personal relationships or assessment of personality to influence the evaluation (1, 2)
1 program 1, 2 program 2 a b
What is excessive depends on whether one is a clinician or researcher
Which option one chooses is influenced by: (a) fear of repercussions to oneself and (b) the natural consequences that will result for the physician who committed the breach
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Participants from program 1 identified two ways of judging whether one conformed to the minimum standard. As one key informant stated, “You don’t have to be all that scrupulous, just don’t do anything excessive.” Another participant suggested the following test: “Ask yourself first, “Would this be okay if it was in the Globe and Mail [a national newspaper]?” Further, what is considered excessive seemed to change as a function of whether one is a clinician or researcher. Program 1 participants believed that researchers had a wider berth regarding what was considered excessive in part because their careers depended more on industry funding than those of clinicians. As one program 1 resident noted: It’s interesting at program 1 because there’s about a 115page pdf document on how the department advises residents to deal with the pharmaceutical industry….but in practice…there’s a lot of senior staff in the department who “…” work very closely with the drug companies. So they publish lots of studies about drugs “…” with the drug companies… No formal policy governing interactions with industry existed in program 2 for the psychiatry program at the time our study was conducted; however, it was a subject of ongoing debate in official meetings. Participants from program 2 could neither agree on what would be unethical nor what would be ideal when interacting with the pharmaceutical industry. A key informant described the situation in the following way: “There’s always that contention, some are staunchly opposed to it, some say that it doesn’t present any moral dilemma to them at all. And then everything in between.” Some program 2 participants believed that everyone should come to independent judgments about what to do. Yet the key informant quoted above did not consider a situation in which individuals were permitted to exercise their moral judgment to be ethically sufficient, noting instead that there should “be some sort of a benchmark set. This is the standard to which we expect you to ascribe. And then people have to make up their own decision from there where they’re going to fall in relation to that.” b) Dealing with Ethical Lapses Participants discussed facing and dealing with the ethical lapses of residents or faculty. Here, we will focus on gray areas, where no prescribed action exists (e.g., faculty cheating on billing, residents not showing up for mandatory activities) rather than lapses for which regulatory authorities already oblige action (e.g., mandatory reporting of sexual relations with patients). The formal, informal, and hidden ethics curricula offered conflicting instruction on how to handle colleagues’ ethical lapses. While residents are taught formally to get involved in recognizing and reporting ethical lapses, involvement might not be obligatory or even desirable for
various reasons. Participants were able to identify an ideal course of action for dealing with ethical lapses (i.e., to address issues directly with the person involved), but the minimum standard for ethical action varied according to one’s professional status. The advantages of going directly to the individual who had engaged in an ethical lapse were captured by the following statements from key informants: “…[regarding] sensitive issues, it is better dealt with, with a minimum number of people involved” and “to see if they are aware of it or to see if there was something you didn’t understand.” Whether one actually did go directly to the person who committed a lapse depended mostly on “the seriousness of the impact on both the patient and the profession” and “whether one has a good enough personal relationship to approach [that person] in a nonthreatening manner.” At the time of an ethical lapse, respect for hierarchy and “fear of repercussions” were the two principal reasons why a resident would not approach an individual directly or become involved via the chain of command (e.g., discussing the issue with one’s direct superior). Residents hesitated to approach someone who is “higher up on the food chain” because, as one resident asked rhetorically, “… who am I to ruin this person’s career?” Residents also considered that “…you’re constantly being evaluated by these people and you have no idea what’s behind their decision-making process.” Thus, out of fear of a bad evaluation, residents said they would be unlikely to address a lapse unless, for example, they had “a staff physician who is comfortable with being challenged, [because] it’s not particularly easy to challenge them without just creating a disaster for yourself.” A disaster could mean the resident becomes “flagged as a trouble-maker” to the detriment of his or her clinical evaluations, or simply becomes known as “that guy who always slows us down by pulling at every little ethical twig in the forest.” Doing nothing might be a means of shielding oneself from trouble, but it can also reflect a considered ethical judgment. One resident explained that lapses would be resolved through natural consequences: “I kind of resolved it by saying, ‘You know what? We’re all responsible for our actions in the end, there’s no point in being a tattletale.’” The resident believed that unethical behavior would eventually be discovered and reprimanded or that it would bring other types of misfortune to the actor. c) Evaluating Residents’ Performance, Particularly Their Professionalism The third topic concerned perceptions of how faculty generated and delivered feedback to residents. This issue was not an ethically challenging situation in the way that the first two topics were because it did not involve a choice of action— residents must be evaluated after all. But, evaluation involves
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ethics in the sense that participants believed that resident evaluations can be informed by choices about what to include and what to omit. Resident participants wanted feedback that was comprehensive and constructive and would foster improvement in their practice. One resident noted the importance of considering a person’s character when evaluating professionalism: “if they could look inside of you that would be preferred.” Instead, professionalism is most often evaluated using objective but superficial criteria that were deemed “impersonal.” These criteria did not necessarily correspond to what residents considered the core of professionalism in psychiatry, namely, according to one resident, “the ability to tolerate emotion, pain, suffering and deal with it in a good way.” Furthermore, residents perceived that feedback did not address the most important areas. For example, one resident noted, “[The evaluations] don’t address the concerns that I have about my performance. Time isn’t provided unless I stop the supervisor and ask, ‘How am I doing in these particular areas where I think I am really dropping the ball?’” A key informant also addressed this issue: “Often when we make an error we don’t necessarily realize we’ve made an error … I hoped training would help me address them … [that] my supervisor would notice I’ve done something wrong and say to me, ‘…I’m wondering if that was the right course of action.’ I find that it’s very rare that a supervisor will say that to you…. Here, you worry about injuring people’s feelings by doing that.” At the same time, residents feared feedback that was not anchored strictly in objective criteria because they might be subject to abuses of power. For example, supervisors might use evaluations to favor residents whom they liked personally; to punish residents who had done something they disliked (e.g., complained or acted as a whistleblower); or to pass judgments on the resident that were beyond the remit of the evaluation (e.g., a resident’s personality). As one resident said, supervisors might judge “how well you get along with people rather than what your specific skills are.” This situation constituted an unethical approach to evaluation, one that fell below the minimum standard. A key informant offered the following explanation for why detailed, critical feedback of residents was uncommon: “…some staff people feel power in some ways but also sort of fearful of residents evaluating them badly or saying things about them that are not really kind of accurate. So some staff err on the side of under-addressing the underperforming resident.”
Discussion We have described the content of the formal, informal, and hidden curricula in ethics at two Canadian psychiatry programs and identified three important topics of ethical concern:
(1) interacting with pharmaceutical companies and representatives; (2) dealing with colleagues’ ethical lapses; and (3) evaluating residents, particularly for professionalism. The curricula diverge on these topics, although the specific nature of these divergences differs according to local characteristics of each program. Our findings contribute, for the first time to our knowledge, to the empirically derived observation that divergent avenues for action were resolved through recourse to a minimum standard of ethics, which enables individuals (both faculty and residents) to avoid trouble even if their behavior falls short of the agreed-upon ideal. For example, addressing colleagues’ ethical lapses was a function of the seriousness of the consequences of action for the intervener and, to a lesser extent, the seriousness of the consequences of the lapse to patients. If taking action could result in a negative reputation or a poor evaluation, then the minimum standard was not to act, but if the quality of patient care was at risk, residents would have to weigh this factor against the potential for personal repercussions. If personal repercussions were unlikely, then the minimum standard was to act whether by going directly to the person or by working through the chain of command. The chain of command had the potential to offer some protection from repercussions (because one’s superior might be able to defend one’s actions or conceal one’s identity), and this would also be considered in the weighing process. When considering their in-training evaluations, residents experienced a tension between their desire for ideal evaluations that allowed for deeper appraisals of their qualities as psychiatrists and their fears that this could lead to abuses of power by faculty. This tension fostered a minimum standard for evaluation in which superficial feedback was given to meet the requirements of evaluation while avoiding hurt feelings and demonstrating that there had been no abuse of power. In discussing the field of psychology, Knapp and VandeCreek [29] describe a two-tier vision of ethics in which there is a “mandatory floor adopted by the profession” (p. 4), including laws and regulatory standards accompanied by disciplinary action for those who fall below this level. There is also an “aspirational” or “voluntary” version of ethics whose aim is to “live out high moral ideas” ([29], p. 4). Scott [30] argues that the law has evolved to serve as a minimum standard for ethical action in health care. Given that legislation governs two central areas of practice in psychiatry—treatment decision-making for incapable patients and hospitalization in situations of actual or threatened harm to self or others—it is unsurprising that psychiatrists might view the law as occupying a central role in ensuring ethical conduct through an externally sanctioned minimum standard of ethics. However, operating within a legal framework may not be the only factor that fosters a default to a minimum standard of ethics. Kuczewski [31] has argued that the emphasis on objective measures and the lack of contact between supervisors and trainees means that professionalism and ethics evaluations
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often focus on negative examples and/or the surveillance of trivial transgressions. He worries that this approach only teaches trainees what they should not do, again establishing a type of minimum standard of professional behavior. Brainard and Brislen [32] confirm this impression, stating that in medical school, “Students learn how to avoid trouble, rather than how to exemplify the virtues of professionals” (p. 1012). The literature concerning the hidden curriculum in ethics offers two principal explanations for how it is perpetuated. These explanations are linked, in turn, to different perspectives on how to address it. Michalec and Hafferty [17] adopt a sociological view, arguing that the hidden curriculum is perpetuated by the very values that are core to the medical profession, namely autonomy and authority. Adopting this perspective means that addressing the hidden curriculum would require coordinated, large-scale action mandated from the profession’s various governing bodies. This view stands in contrast to the growing interest in role-modeling [33, 34] and how it promotes both positive and negative values to learners. Here, the message is that values of the hidden curriculum are transmitted through interactions between individual faculty members and trainees rather than through the structure of the profession or of a given institution [35]. According to this view, addressing the hidden curriculum would involve trying to change faculty behavior. This view places the functioning of the hidden curriculum in the hands of individual faculty members and means that efforts to address it will have to be particular: teacher by teacher. Our findings point to a third, intermediate way of conceptualizing the hidden curriculum. Instead of seeing it as embedded either in high-level professional values or in individual behavior, our analysis suggests that the content and functioning of the hidden curriculum varies along a great many midlevel parameters, including local culture; emphasis of the program (e.g., academic versus clinical); and the nature of faculty-resident relationships. As a result, there may be values from the hidden curriculum that are particularly important in certain programs, specialties, or regions. For example, in our study, interacting with the pharmaceutical industry was a preoccupation at both sites. However, the messages from the formal, informal, and hidden ethics curricula differed between sites, as did the options for ethically acceptable action. Our analysis suggests that addressing the content of the hidden curriculum in postgraduate training programs will necessarily be a piecemeal affair, at different levels (locally, provincially or nationally) and in different specialties, depending on the issue. Thus, the first step to addressing the hidden curriculum is to determine what issues are at play in any given program and which ones can be addressed locally versus those that require larger-scale collaboration and action. The strengths of our study include its attempt to describe empirically the actual content of the hidden curriculum. Studying two different programs offered us the opportunity
to make comparisons about the content of the hidden curriculum and the divergences between the formal, informal, and hidden ethics curricula in very different contexts. It is also worth noting limitations of this project. First, a single study cannot capture every element of the hidden curriculum. Other research methods may have identified additional issues. For example, our account of the hidden curriculum emerged largely from individual retrospection. Our analysis would have been strengthened through longitudinal observation at each site, but this was not feasible with the available resources. Second, we faced the inherent limitation of trying to study something that is hidden. During the course of our study, we noted that, at each site, there were topics that participants avoided discussing despite being flagged as important in the document review or by key informants. We may not have had access to the thorniest problems, and thus, our analysis may not apply equally well to them. The analysis and findings of our study offer a useful starting point for other programs wishing to reflect upon the content and functioning of their hidden ethics curricula. Fruitful areas of future investigation include the evaluation of efforts to address the hidden curriculum in ethics and the extent to which unwanted divergences can be addressed successfully by efforts intended to combat them. Implications for Academic Leaders • The existence of a minimum standard of ethics may offer an explanation for the divergences between formal ethics education and the hidden ethics curriculum in postgraduate psychiatry training. • Formal ethics education is often aspirational, while a minimum standard of ethics encourages residents and faculty to avoid trouble and do what is ethically required rather than what is ideal. • Programs wishing to address the impact of the hidden curriculum in ethics should consider a multi-pronged approach involving program-, geographic-, and specialty-specific action.
Compliance with Ethical Standards Conflict of interest On behalf of all authors, the corresponding author states that there is no conflict of interest. Funding Source Royal College of Physicians and Surgeons of Canada.
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Creswell JW. Educational research: planning, conducting, and evaluating quantitative and qualitative research. 2nd ed. Upper Saddle River, New Jersey: Prentice Hall; 2005. Hatch JA. Doing qualitative research in education settings. Albany: State University of New York Press; 2002. Baxter P, Jack S. Qualitative case study methodology: study design and implementation for novice researchers. Qual Rep. 2008;13: 544–59. Stake RE. The art of case study research. Thousand Oaks, CA: Sage; 1995. Yin RK. Case study research: design and methods. 3rd ed. Thousand Oaks, California: Sage Publications; 2003. Bogden RC, Bilken SK. Qualitative research in education: an introduction to theories and methods. 4th ed. New York: Allyn and Bacon; 2003. Creswell JW. Qualitative inquiry and research design: choosing among five traditions. Thousand Oaks, California: Sage Publications; 1997. Miles MB, Huberman AM. Qualitative data analysis: an expanded source book. 2nd ed. Thousand Oaks, California: Sage Publications; 1994. Department of Psychiatry Task Force Report: Interactions with the Pharmaceutical Industry (PDF). Available at: http://www.medicine. utoronto.ca/research/ethics-policies-and-guidelines. Accessed June 15, 2014. Knapp SJ, VandeCreek LD. Practical ethics for psychologists: a positive approach. 2nd ed. Washington, DC: American Psychological Association; 2012. p. 1–14. Scott C. Why law pervades medicine: an essay on ethics in healthcare. Notre Dame J Law Ethics Public Policy. 2000;14: 245–303. Kuczewski M. The problem with evaluating professionalism: the case against the current dogma. In: Wear D, Aultman JM, editors. Professionalism in medicine: critical perspectives. New York: Springer; 2006. p. 185–98. Brainard AH, Brislen HC. Learning professionalism: a view from the trenches. Acad Med. 2007;82:1010–4. Baernstein A, Amies Oelschlager AE, Chang TA, Wenrich MD. Learning professionalism: perspectives of preclinical medical students. Acad Med. 2009;84:574–81. Kenny NP, Mann KV, MacLeod H. Role modeling in physicians’ professional formation: reconsidering and essential but untapped educational strategy. Acad Med. 2003;78:1203–10. Hicks LK, Robertson DW, Robinson DL, Woodrow SI. Understanding the clinical dilemmas that shape medical students’ ethical development: questionnaire survey and focus group study. BMJ. 2001;322:709–10.
EMPIRICAL REPORT
The Hidden Ethics Curriculum in Two Canadian Psychiatry Residency Programs: A Qualitative Study Mona Gupta 1 & Cynthia Forlini 2 & Keith Lenton 3 & Raquel Duchen 4 & Lynne Lohfeld 5
Received: 7 September 2014 / Accepted: 22 October 2015 # Academic Psychiatry 2015
Abstract Objective The authors describe the hidden ethics curriculum in two postgraduate psychiatry programs. Methods Researchers investigated the formal, informal, and hidden ethics curricula at two demographically different postgraduate psychiatry programs in Canada. Using a case study design, they compared three sources: individual interviews with residents and with faculty and a semi-structured review of program documents. They identified the formal, informal, and hidden curricula at each program for six ethics topics and grouped the topics under two thematic areas. They tested the applicability of the themes against the specific examples under each topic. Results pertaining to one of the themes and its three topics are reported here. Results Divergences occurred between the curricula for each topic. The nature of these divergences differed according to local program characteristics. Yet, in both programs, choices for action in ethically challenging situations were mediated by a minimum standard of ethics that led individuals to avoid trouble even if this meant their behavior fell short of the accepted ideal.
* Mona Gupta [email protected] 1
l’Université de Montréal, Montréal, QC, Canada
2
The University of Queensland Centre for Clinical Research, St Lucia, QLD, Australia
3
McGill University, Montréal, QC, Canada
4
Institute for Clinical Evaluative Sciences, Toronto, ON, Canada
5
McMaster University, Hamilton, ON, Canada
Conclusions Effective ethics education in postgraduate psychiatry training will require addressing the hidden curriculum. In addition to profession-wide efforts to articulate high-level values, program-specific action on locally relevant issues constitutes a necessary mechanism for handling the impact of the hidden curriculum.
Keywords Psychiatry residents . Ethics . Professional development
Although ethics education has long been a component of undergraduate medical education, the Royal College of Physicians and Surgeons of Canada now requires that it be provided within all postgraduate training programs as well [1] and has made substantial efforts toward developing an ethics curriculum for residency training [2]. Several authors have pointed out that formal ethics education operates in parallel with informal and hidden ethics curricula, the latter being more subtle, pervasive, and influential in shaping the learning environment and student behavior [3, 4]. The informal curriculum consists of unscripted, interpersonal forms of teaching and learning that take place between faculty and students, whereas the hidden curriculum refers to influences at organizational and cultural levels that inform the learning process [5] and can undermine the formal content. Previous analyses of the impact of the hidden curriculum have suggested that, if unaddressed, negative values and behaviors inculcated through it can lead to ethical erosion instead of ethical development as training progresses [6–9]. Thus, the Future of Medical Education Postgraduate Project report [10], funded by Health Canada, recommends that postgraduate education organizations and faculties of medicine attempt to address the counterproductive elements of the hidden curriculum.
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Addressing the impact of the hidden curriculum in postgraduate education requires knowledge of how it operates in that particular context. However, our understanding of it is based primarily on studies in undergraduate medical programs (e.g., [11–14]). Therefore, we decided to investigate the formal, informal, and hidden ethics curricula at two postgraduate training programs in the same specialty. Recently, Van Deven and colleagues [15] adopted a similar approach in radiology. We chose to focus on psychiatry training because of our participation and professional experience in postgraduate education in psychiatry, which we believed would help us better understand the views and experiences of our study participants. We aimed to compare and contrast the content of the formal, informal, and hidden ethics curricula in two demographically different postgraduate psychiatry programs (hereafter program 1 and program 2) and to explain potential divergences between the three curricula. To achieve these aims, we compared findings from three sources of data: individual interviews with residents and with faculty and relevant documents from each program. This in-depth qualitative study serves as a useful empirical complement to the existing conceptual work on the hidden curriculum in ethics, which lays out, on theoretical grounds, the high-level values embedded within the culture of the medical profession that motivate the hidden curriculum [16–19].
Methods Study Design and Setting We decided to use qualitative case study as our overall research design because it is appropriate when (1) the phenomenon of interest is ongoing rather than historical and cannot be separated from the context in which it occurs and (2) researchers want to answer “how” and “why” questions in addition to determining what is happening in the situation under study [20, 21]. Specifically, we conducted an instrumental case study because we were using the cases (the programs) to gain insight into the issue of the potential divergences between the formal, informal, and hidden ethics curricula rather than evaluating the specific programs themselves. We also decided to conduct a multiple- rather than single-case study because we wanted to gain in-depth understanding of the issue by comparing data from two very different contexts that were likely to shape study participants’ experiences and views on ethics training in their programs [22–24]. Although all psychiatry postgraduate programs in Canada must adhere to the same nationally mandated formal curriculum in terms of specific rotations and their content, we intentionally chose two programs that contrasted in location and size to facilitate our comparison.
Sources and Data Collection A hallmark of the qualitative case study design is collecting and comparing findings from multiple sources of data (triangulation) to gain a deep understanding of the topic under study [25, 26]. For each program we collected data from three sources to achieve triangulation: (1) documents from the program, hospital or faculty (e.g., ethics curriculum documents, ethics policy papers, and departmental mission statements); (2) key informants (i.e., faculty and residents who, because of their roles in their programs, had insider knowledge about key ethical issues); and (3) resident volunteers. To preserve confidentiality, we will not name the specific roles of potential key informants. Given the potentially sensitive subject matter of the interviews, the study team took particular care to recruit participants using confidential means (e.g., by individual mailings rather than group announcements) and to offer to conduct interviews away from their base hospital if participants wished. Focus group participants additionally agreed to confidentiality of matters discussed within the group. The study received formal research ethics board approval at both locations. Each participant gave informed consent before participating in the study. A semi-structured document review enabled us to describe the formal ethics curriculum for each program, develop questions for the individual interviews, and identify potential key informants. This was an information-gathering step only, to which we did not apply a specific theoretical framework. We developed the interview guides through team discussion and a review of the extant literature. This process enabled us to develop open-ended questions, whereas our document review enabled us to develop program-appropriate probes to these general questions. We recruited 19 key informants from program 1 (47 % of whom were residents) and 5 from program 2 (20 % of whom were residents). Because we also interviewed residents in the second phase of interviewing, we were not concerned that the key informant group had only one resident in program 2. One potential program 1 key informant declined to participate on the grounds that it was “too risky”; we were not able to obtain any further information about this decision. An interviewer at each site, unknown to the participants and working outside the program, conducted a semi-structured interview following the interview guide with each key informant. We then invited participation from the entire resident body at each site. We recruited 16 resident volunteers in program 1 (out of the approximately 100 remaining residents not identified as potential key informants) and 8 in program 2 (out of approximately 14). These semistructured interviews were conducted by the project’s resident co-investigators, who were also unknown to the interviewees. The resident co-investigators acted as interviewers for the resident interviews at their counterpart program as
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part of the training opportunity offered by the research project. All interviewers participated in a formal training session with an experienced qualitative researcher. The training involved a review and discussion of interviewing methods and skills, practice interviews using the draft interview guide to identify potential challenges that could arise in interviewing, and feedback on each interviewer’s interviewing technique. For logistical reasons, the interviewer for the program 2 key informants participated in-training sessions via telephone. The training ensured consistency in the interviewers’ techniques and interview quality. The individual interviews with both key informants and residents asked participants to reflect on what ethics is; how it is taught, learned, and evaluated; how it manifests in behavior and character; how the programs communicate and embody ethics to faculty and trainees; and the ethical issues that were of concern within the programs. Each interview was audio-taped and transcribed, except for one in which the participant declined to be taped but agreed to have statements recorded via field notes taken by the interviewer. The interviewers reviewed the transcripts of their interviews to correct any transcription errors. The researchers sent the corrected transcript and a summary of key points to each participant for review, corrections, or withdrawals. We then identified a small number of tentative, emerging, thematic areas for the two programs. We used a focus group discussion at each site with resident volunteers (recruited via open invitation) to confirm and refine, or disconfirm, these themes.
they self-identify as students versus professionals, influence how they respond to ethically difficult situations where there are curricular divergences. The two themes subsumed six ethical issues or topics (there were three topics under each theme). We examined the plausibility and applicability of two themes through extensive review and testing against the interview data. That is, for each instance in which a participant spoke about one of the topics, we tried to determine whether the theme applied to what was described. In this paper, we report on the first theme and its three topics.
Results Three topics that elicited ethical concern for the participants in our study included (1) interactions with the pharmaceutical industry, (2) dealing with colleagues’ ethical lapses, and (3) evaluating residents’ performance, especially when addressing professionalism (Table 1). These three topics were noted and/ or elaborated upon in detail by key informants and residents alike. In the following section, we will identify the overall message transmitted via the formal, informal, and hidden curricula for each topic, indicating the divergences between curricula where they arose. We will support these findings through direct quotations from 17 of our 48 participants (35 %). Our analysis points to the overarching theme of a minimum standard of ethics, which explains curricular divergence and shapes the options for action in ethically challenging situations.
Data Coding and Analysis
Explaining Curricular Divergence: The Minimum Standard of Ethics
Our analysis followed methods described by various case study researchers whose guidelines are an accepted part of the qualitative research literature [22, 23, 27]. Our data organization and analytic processes involved two or more analysts at all times. First, we organized the data descriptively under the headings of formal, informal, and hidden curriculum using a qualitative data management software program (Nvivo7). We identified various ethics topics in each curriculum, linked them to specific examples in the interviews, and described the formal, informal, and hidden message about that topic. We then searched for convergences and divergences between the three curricula, as well as similarities and differences between the two programs. We identified six topics of concern in both programs for which there were divergences between the curricula. Through ongoing, iterative discussion among the analysts, we then identified two themes concerning curricular divergence. The two themes were: (1) for certain ethically challenging issues, divergences between the formal, informal and hidden ethics curricula can be explained and resolved via the operation of a “minimum standard of ethics”; and (2) residents’ identities in their training years, specifically whether
Residents witnessed divergences between what they were taught formally, what they learned informally through supervision and other clinical interactions, and what they absorbed through the hidden curriculum. Why do these divergences occur, and how do individual residents determine the correct course of action in the face of these divergences in ethically challenging situations? Participants identified a basic level of behavior that was considered acceptable in any given situation—a minimum standard of ethics. To fall below this threshold was unethical, whereas to go beyond it was ideal. Of these two options, it was often easier for the participants to identify what fell below the minimum standard. As one key informant from program 2 noted, “What constitutes professionalism in our discipline, in our profession, is more obvious when there is an egregious breach than when there is a positive professionalism displayed. So, it’s only when somebody falls below what seems to be the general standard that this comes to light.” By knowing what is unethical, that is, what one should not do, residents could identify ethically acceptable alternatives. The most laudable course of action represented what a good or ideal physician would do. Awareness of the ideal, however,
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Divergences in the messages arising from formal, informal and hidden curricula in postgraduate psychiatry training at program 1 and program 2
Topics of ethical concern
Message from the formal curriculum
Message from the informal curriculum
Message from the hidden curriculum
1. Interactions with pharmaceutical companies and representatives
Do not interact with industry. (1)
Interact if you wish, but don’t do anything excessive. (1)
There is no consensus about what is unethical. (1, 2) You have more liberty if you are a researcher. (1)
Getting involved is optional. (1, 2)
Whatever you do, don’t get in trouble. This might mean you do nothing. (1>2)*
No message (1, 2)
Your personal relationship with a supervisor and your personality will influence your evaluations. (1, 2)
2. Dealing with colleagues’ ethical lapses
3. Formal evaluations of residents’ performance, particularly their professionalism
Everyone should make his/her own decision about whether or not to interact. (2) Report the problem via the chain of command or go directly to the person to address it with him/her (1,2) Evaluations should be conducted according to objective standards; and should adhere to the CANMEDs roles. (1, 2)
* This message was emphasized to a greater extent in program 1 than in program 2
was insufficient to guide action due to constraints such as respect for, or fear of, hierarchy or lack of time. For each of the three ethics topics shown in Table 1, participants described a course of action that allows the physician to meet the ethical obligations of the “good enough physician,” which represented a compromise between the ideal and the unethical. This minimum standard sustains divergence between what is formally taught and what is actually done day to day in the programs (Table 2). a) Interactions with the Pharmaceutical Industry How one should interact with the pharmaceutical industry was a major ethical issue identified by respondents at both sites. Program 1 has a written policy discussing such interactions, which made up part of the formal ethics curriculum for this topic [28]. The major concern discussed in the document was avoiding “perceived and real conflict(s) of interest in the complex Table 2
relationship between physicians and the pharmaceutical industry” (p. 2). In program 1, being in or even being perceived to be in a conflict of interest was considered below the minimum standard for ethical behavior, which one key informant there described as: … working very closely with the company as a consultant or a member of an advisory board, and then writing guidelines that have to do with the products of those companies. Or giving talks in inappropriate venues where the talk is promotional, and where the meal in one of the best restaurants in “…” clearly is more of an inducement than the talk itself. Situations where faculty members allow representatives of industry to have kind of inappropriate access to the residents and medical students. At the same time, seeing that faculty members interacted with industry showed that some interaction was permissible.
Influence of the minimum standard on the choice of action in the ethically challenging situations at each program
Ideal
Minimum standard
How physicians should interact with pharmaceutical companies
How physicians should deal with a colleague’s ethical lapse
How faculty should give feedback to residents about professionalism
No contact with pharma to avoid real or perceived COI (1) No consensus (2) Don’t do anything excessivea (1)
Address issues directly with the individual (1, 2)
Feedback should be comprehensive, constructive, and personal (1, 2)
Option 1b – follow the chain of command (1, 2) Option 2b – say nothing (1, 2) No message
Give an objective assessment, even if trivial, without offending (1, 2)
Follow individual values (2) Below minimum standard
Participating in activities that are promotional or non-scientific (1) No consensus (2)
Allowing personal relationships or assessment of personality to influence the evaluation (1, 2)
1 program 1, 2 program 2 a b
What is excessive depends on whether one is a clinician or researcher
Which option one chooses is influenced by: (a) fear of repercussions to oneself and (b) the natural consequences that will result for the physician who committed the breach
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Participants from program 1 identified two ways of judging whether one conformed to the minimum standard. As one key informant stated, “You don’t have to be all that scrupulous, just don’t do anything excessive.” Another participant suggested the following test: “Ask yourself first, “Would this be okay if it was in the Globe and Mail [a national newspaper]?” Further, what is considered excessive seemed to change as a function of whether one is a clinician or researcher. Program 1 participants believed that researchers had a wider berth regarding what was considered excessive in part because their careers depended more on industry funding than those of clinicians. As one program 1 resident noted: It’s interesting at program 1 because there’s about a 115page pdf document on how the department advises residents to deal with the pharmaceutical industry….but in practice…there’s a lot of senior staff in the department who “…” work very closely with the drug companies. So they publish lots of studies about drugs “…” with the drug companies… No formal policy governing interactions with industry existed in program 2 for the psychiatry program at the time our study was conducted; however, it was a subject of ongoing debate in official meetings. Participants from program 2 could neither agree on what would be unethical nor what would be ideal when interacting with the pharmaceutical industry. A key informant described the situation in the following way: “There’s always that contention, some are staunchly opposed to it, some say that it doesn’t present any moral dilemma to them at all. And then everything in between.” Some program 2 participants believed that everyone should come to independent judgments about what to do. Yet the key informant quoted above did not consider a situation in which individuals were permitted to exercise their moral judgment to be ethically sufficient, noting instead that there should “be some sort of a benchmark set. This is the standard to which we expect you to ascribe. And then people have to make up their own decision from there where they’re going to fall in relation to that.” b) Dealing with Ethical Lapses Participants discussed facing and dealing with the ethical lapses of residents or faculty. Here, we will focus on gray areas, where no prescribed action exists (e.g., faculty cheating on billing, residents not showing up for mandatory activities) rather than lapses for which regulatory authorities already oblige action (e.g., mandatory reporting of sexual relations with patients). The formal, informal, and hidden ethics curricula offered conflicting instruction on how to handle colleagues’ ethical lapses. While residents are taught formally to get involved in recognizing and reporting ethical lapses, involvement might not be obligatory or even desirable for
various reasons. Participants were able to identify an ideal course of action for dealing with ethical lapses (i.e., to address issues directly with the person involved), but the minimum standard for ethical action varied according to one’s professional status. The advantages of going directly to the individual who had engaged in an ethical lapse were captured by the following statements from key informants: “…[regarding] sensitive issues, it is better dealt with, with a minimum number of people involved” and “to see if they are aware of it or to see if there was something you didn’t understand.” Whether one actually did go directly to the person who committed a lapse depended mostly on “the seriousness of the impact on both the patient and the profession” and “whether one has a good enough personal relationship to approach [that person] in a nonthreatening manner.” At the time of an ethical lapse, respect for hierarchy and “fear of repercussions” were the two principal reasons why a resident would not approach an individual directly or become involved via the chain of command (e.g., discussing the issue with one’s direct superior). Residents hesitated to approach someone who is “higher up on the food chain” because, as one resident asked rhetorically, “… who am I to ruin this person’s career?” Residents also considered that “…you’re constantly being evaluated by these people and you have no idea what’s behind their decision-making process.” Thus, out of fear of a bad evaluation, residents said they would be unlikely to address a lapse unless, for example, they had “a staff physician who is comfortable with being challenged, [because] it’s not particularly easy to challenge them without just creating a disaster for yourself.” A disaster could mean the resident becomes “flagged as a trouble-maker” to the detriment of his or her clinical evaluations, or simply becomes known as “that guy who always slows us down by pulling at every little ethical twig in the forest.” Doing nothing might be a means of shielding oneself from trouble, but it can also reflect a considered ethical judgment. One resident explained that lapses would be resolved through natural consequences: “I kind of resolved it by saying, ‘You know what? We’re all responsible for our actions in the end, there’s no point in being a tattletale.’” The resident believed that unethical behavior would eventually be discovered and reprimanded or that it would bring other types of misfortune to the actor. c) Evaluating Residents’ Performance, Particularly Their Professionalism The third topic concerned perceptions of how faculty generated and delivered feedback to residents. This issue was not an ethically challenging situation in the way that the first two topics were because it did not involve a choice of action— residents must be evaluated after all. But, evaluation involves
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ethics in the sense that participants believed that resident evaluations can be informed by choices about what to include and what to omit. Resident participants wanted feedback that was comprehensive and constructive and would foster improvement in their practice. One resident noted the importance of considering a person’s character when evaluating professionalism: “if they could look inside of you that would be preferred.” Instead, professionalism is most often evaluated using objective but superficial criteria that were deemed “impersonal.” These criteria did not necessarily correspond to what residents considered the core of professionalism in psychiatry, namely, according to one resident, “the ability to tolerate emotion, pain, suffering and deal with it in a good way.” Furthermore, residents perceived that feedback did not address the most important areas. For example, one resident noted, “[The evaluations] don’t address the concerns that I have about my performance. Time isn’t provided unless I stop the supervisor and ask, ‘How am I doing in these particular areas where I think I am really dropping the ball?’” A key informant also addressed this issue: “Often when we make an error we don’t necessarily realize we’ve made an error … I hoped training would help me address them … [that] my supervisor would notice I’ve done something wrong and say to me, ‘…I’m wondering if that was the right course of action.’ I find that it’s very rare that a supervisor will say that to you…. Here, you worry about injuring people’s feelings by doing that.” At the same time, residents feared feedback that was not anchored strictly in objective criteria because they might be subject to abuses of power. For example, supervisors might use evaluations to favor residents whom they liked personally; to punish residents who had done something they disliked (e.g., complained or acted as a whistleblower); or to pass judgments on the resident that were beyond the remit of the evaluation (e.g., a resident’s personality). As one resident said, supervisors might judge “how well you get along with people rather than what your specific skills are.” This situation constituted an unethical approach to evaluation, one that fell below the minimum standard. A key informant offered the following explanation for why detailed, critical feedback of residents was uncommon: “…some staff people feel power in some ways but also sort of fearful of residents evaluating them badly or saying things about them that are not really kind of accurate. So some staff err on the side of under-addressing the underperforming resident.”
Discussion We have described the content of the formal, informal, and hidden curricula in ethics at two Canadian psychiatry programs and identified three important topics of ethical concern:
(1) interacting with pharmaceutical companies and representatives; (2) dealing with colleagues’ ethical lapses; and (3) evaluating residents, particularly for professionalism. The curricula diverge on these topics, although the specific nature of these divergences differs according to local characteristics of each program. Our findings contribute, for the first time to our knowledge, to the empirically derived observation that divergent avenues for action were resolved through recourse to a minimum standard of ethics, which enables individuals (both faculty and residents) to avoid trouble even if their behavior falls short of the agreed-upon ideal. For example, addressing colleagues’ ethical lapses was a function of the seriousness of the consequences of action for the intervener and, to a lesser extent, the seriousness of the consequences of the lapse to patients. If taking action could result in a negative reputation or a poor evaluation, then the minimum standard was not to act, but if the quality of patient care was at risk, residents would have to weigh this factor against the potential for personal repercussions. If personal repercussions were unlikely, then the minimum standard was to act whether by going directly to the person or by working through the chain of command. The chain of command had the potential to offer some protection from repercussions (because one’s superior might be able to defend one’s actions or conceal one’s identity), and this would also be considered in the weighing process. When considering their in-training evaluations, residents experienced a tension between their desire for ideal evaluations that allowed for deeper appraisals of their qualities as psychiatrists and their fears that this could lead to abuses of power by faculty. This tension fostered a minimum standard for evaluation in which superficial feedback was given to meet the requirements of evaluation while avoiding hurt feelings and demonstrating that there had been no abuse of power. In discussing the field of psychology, Knapp and VandeCreek [29] describe a two-tier vision of ethics in which there is a “mandatory floor adopted by the profession” (p. 4), including laws and regulatory standards accompanied by disciplinary action for those who fall below this level. There is also an “aspirational” or “voluntary” version of ethics whose aim is to “live out high moral ideas” ([29], p. 4). Scott [30] argues that the law has evolved to serve as a minimum standard for ethical action in health care. Given that legislation governs two central areas of practice in psychiatry—treatment decision-making for incapable patients and hospitalization in situations of actual or threatened harm to self or others—it is unsurprising that psychiatrists might view the law as occupying a central role in ensuring ethical conduct through an externally sanctioned minimum standard of ethics. However, operating within a legal framework may not be the only factor that fosters a default to a minimum standard of ethics. Kuczewski [31] has argued that the emphasis on objective measures and the lack of contact between supervisors and trainees means that professionalism and ethics evaluations
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often focus on negative examples and/or the surveillance of trivial transgressions. He worries that this approach only teaches trainees what they should not do, again establishing a type of minimum standard of professional behavior. Brainard and Brislen [32] confirm this impression, stating that in medical school, “Students learn how to avoid trouble, rather than how to exemplify the virtues of professionals” (p. 1012). The literature concerning the hidden curriculum in ethics offers two principal explanations for how it is perpetuated. These explanations are linked, in turn, to different perspectives on how to address it. Michalec and Hafferty [17] adopt a sociological view, arguing that the hidden curriculum is perpetuated by the very values that are core to the medical profession, namely autonomy and authority. Adopting this perspective means that addressing the hidden curriculum would require coordinated, large-scale action mandated from the profession’s various governing bodies. This view stands in contrast to the growing interest in role-modeling [33, 34] and how it promotes both positive and negative values to learners. Here, the message is that values of the hidden curriculum are transmitted through interactions between individual faculty members and trainees rather than through the structure of the profession or of a given institution [35]. According to this view, addressing the hidden curriculum would involve trying to change faculty behavior. This view places the functioning of the hidden curriculum in the hands of individual faculty members and means that efforts to address it will have to be particular: teacher by teacher. Our findings point to a third, intermediate way of conceptualizing the hidden curriculum. Instead of seeing it as embedded either in high-level professional values or in individual behavior, our analysis suggests that the content and functioning of the hidden curriculum varies along a great many midlevel parameters, including local culture; emphasis of the program (e.g., academic versus clinical); and the nature of faculty-resident relationships. As a result, there may be values from the hidden curriculum that are particularly important in certain programs, specialties, or regions. For example, in our study, interacting with the pharmaceutical industry was a preoccupation at both sites. However, the messages from the formal, informal, and hidden ethics curricula differed between sites, as did the options for ethically acceptable action. Our analysis suggests that addressing the content of the hidden curriculum in postgraduate training programs will necessarily be a piecemeal affair, at different levels (locally, provincially or nationally) and in different specialties, depending on the issue. Thus, the first step to addressing the hidden curriculum is to determine what issues are at play in any given program and which ones can be addressed locally versus those that require larger-scale collaboration and action. The strengths of our study include its attempt to describe empirically the actual content of the hidden curriculum. Studying two different programs offered us the opportunity
to make comparisons about the content of the hidden curriculum and the divergences between the formal, informal, and hidden ethics curricula in very different contexts. It is also worth noting limitations of this project. First, a single study cannot capture every element of the hidden curriculum. Other research methods may have identified additional issues. For example, our account of the hidden curriculum emerged largely from individual retrospection. Our analysis would have been strengthened through longitudinal observation at each site, but this was not feasible with the available resources. Second, we faced the inherent limitation of trying to study something that is hidden. During the course of our study, we noted that, at each site, there were topics that participants avoided discussing despite being flagged as important in the document review or by key informants. We may not have had access to the thorniest problems, and thus, our analysis may not apply equally well to them. The analysis and findings of our study offer a useful starting point for other programs wishing to reflect upon the content and functioning of their hidden ethics curricula. Fruitful areas of future investigation include the evaluation of efforts to address the hidden curriculum in ethics and the extent to which unwanted divergences can be addressed successfully by efforts intended to combat them. Implications for Academic Leaders • The existence of a minimum standard of ethics may offer an explanation for the divergences between formal ethics education and the hidden ethics curriculum in postgraduate psychiatry training. • Formal ethics education is often aspirational, while a minimum standard of ethics encourages residents and faculty to avoid trouble and do what is ethically required rather than what is ideal. • Programs wishing to address the impact of the hidden curriculum in ethics should consider a multi-pronged approach involving program-, geographic-, and specialty-specific action.
Compliance with Ethical Standards Conflict of interest On behalf of all authors, the corresponding author states that there is no conflict of interest. Funding Source Royal College of Physicians and Surgeons of Canada.
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