Combating Medicine’s Hidden Curriculum

Stefan Wheat
Stefan Wheat, ’18

“But we had forgotten that alongside Orwell‘s dark vision, there was another – slightly older, slightly less well known, equally chilling: Aldous Huxley‘s Brave New World. Orwell warns that we will be overcome by an externally imposed oppression. But in Huxley‘s vision, no Big Brother is required to deprive people of their autonomy, maturity and history.”

-Neil Postman

My family reached the saddle of Thorung La pass on day fifteen of our twenty-one day trek of the Annapurna Circuit in Nepal, the 300 km trail encircling the Annapurna massif. On day sixteen I turned nine years old, and on day seventeen I developed appendicitis. That first night after I began to develop symptoms, I remember clearly when our sirdar, the leader of our expedition, entered the tent where I was screaming bloody murder—writhing in pain, but perfectly lucid. He sang a very tranquil song in Nepali and proceeded to inform my father—within clear earshot of myself—that he did not think I would survive to reach the nearest hospital. This marked my first experience with poor bedside manner.

Now, one year after returning from an elective in Harare, Zimbabwe through the University of Vermont College of Medicine’s global health program and with the experience of most of my third year clerkships behind me, I can see that my experience in Nepal is far from the exception with respect to appropriate modeling of patient care. Indeed, the “hidden curriculum”—the process by which the bright-eyed compassion for the human condition that drives students to the practice of medicine is snuffed out and replaced by callous apathy—is an ever-present feature of medical education. One particularly insidious feature of the hidden curriculum is that it treats compassion as a fixed trait, rather than one that can be cultivated as an educational goal.

Unfortunately, global health education is not spared the profoundly damaging influence of the hidden curriculum. Just as the pressures of medical education can lead to apathy and indifference, the heavy burden of the global health agenda combined with the critical needs of planetary health can overwhelm the compassion that drives students to care about the interconnected and interdependent global medical and environmental initiatives. After all, how can adding the complexity of environmentalism to the equation serve to promote, much less expedite, the execution of the sustainable development goals? True, it is critical that students be mindful of the complexity of the issues posed by the planetary health initiative and that they consider both the feasibility and sustainability of their efforts. However, the opportunity offered by our increasingly global community coupled with the unique challenges posed by the planetary health movement make now precisely the occasion for lofty ambition and the time to fight the forces of cynicism.

We cannot separate human health from the health of our global environment, and apathy has no role in the efforts to tackle the formidable challenges posed by the one health initiative. How, then, do we as students combat the apathy bred by the hidden curriculum found in medical education? First, we must identify those individuals who we wish to emulate as models of compassionate care, and recognize such individuals precisely for their ability to engender empathy within the confines of rigorous science. My time in Zimbabwe was highlighted by working with Ruth, my teaching resident, who exemplified daily the qualities of a compassionate physician. I remember watching her on one of our first nights in the emergency room as she helped another resident perform an emergent pericardiocentesis for a patient with tamponade while still closely monitoring the fourteen-year-old boy behind her with idiopathic toxic epidermal necrolysis. While later reflecting on the chaos of that night, Ruth lamented that she was not able to do more for the boy and resolved to follow up on the patient’s case with the host-country resident. In so doing, Ruth taught me that developing the skills for delivering compassionate care, far from being fixed, is the work of a lifetime and the most valuable ability a physician can cultivate.

Beyond identifying role models for the delivery of compassionate care, it is critical that we cherish and nurture our goals and believe in a path forward that can encompass the lofty ambitions of global and planetary health. Volunteering in Indonesian Borneo for Health in Harmony was the single most inspiring professional experience of my life. Working for an organization whose mission explicitly combined environmental sustainability with access to healthcare for underserved populations was invaluable to me as a bridge between my passion for environmentalism and my choice to pursue a career as a physician. Attending the 2016 CUGH conference in San Francisco and witnessing global health’s shift toward emphasizing planetary health reaffirmed my desire to expand upon the model I saw in Indonesia.

In the pursuit of the ambitions of planetary health and the one health initiative, we must remain cognizant of the frailty of the human psyche in the face of overwhelming challenges. The great task confronting this movement is similar to the challenge presented by the hidden curriculum of medical education: paralyzed by what can feel like an insurmountable undertaking, humans are prone to indifference. While George Orwell’s warning against the dangers of censorship in “Nineteen Eighty-Four” was in keeping with the fears of the 20th century, Aldous Huxley’s “Brave New World” more closely approximates the perils of the 21st. Where Orwell cautioned against the concealment of information, Huxley lamented “man’s almost infinite appetite for distractions.” Orwell envisioned the path to ruin paved by guns and violence, Huxley by detachment and apathy. However, as anyone who has worked abroad in global health can attest, the warmth of the people you meet breeds a sense of investment that leaves no room for apathy. Global health has thus provided me with the tools and the drive to pursue my goals and to rage against the complacency and insensitivity engendered by the hidden curriculum.  

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