The Hidden Curriculum in Anaesthesia
P.J. Moran1, J.J. Bates1
1. Department of Anaesthesia, National University of Ireland, Galway, Ireland.
The Hidden Curriculum, a metaphor for passive subconscious learning in the work place, is underreported yet highly influential in Anaesthesia Training.
Its’ importance became apparent to me during a six month post as clinical tutor in a teaching hospital. Part of my job description was to give weekly large group teaching to 3rd year medical students about various topics relating to the speciality. Medical students have very little exposure to anaesthesia at undergraduate level as exams revolve around the other acute hospital specialities, so I felt the need to give a brief introduction at the start of each rotation:
“Being an anaesthetist is like being Batman. No-one knows who you are. No-one really knows what you do.….but when things go wrong, and chaos ensues, the answer will always be:
…CALL THE ANAESTHETIST”
Anaesthetists have various roles in our healthcare system. These include the management of critically ill patients in the Intensive Care Unit, inserting epidurals on the labour ward, or managing busy theatre emergency lists. As an anaesthetist in charge of an emergency list you are burdened with the task of being a patient advocate while simultaneously managing multiple surgical personalities and their patient concerns, in order to come up with the ‘most appropriate’ order for surgical procedures in an environment where resources are frequently stretched. This is combined with the constant awareness of, and vigilance for, problems threatening the anaesthetised patient.
With this in mind one would be led to believe that anaesthetic teaching would involve development of a diverse range of skills outside of information acquisition and clinical skill attainment.
A qualitative study of non-technical skills by Larsson and Holmstrom, highlights that the most valuable non-technical skills are: Organisation, Communication, Maintaining situational awareness during practical work and Leadership.1
They also report that excellent anaesthetists are ‘patient centred’ and ‘humble to the complexity of anaesthesia while admitting own fallibility’1
With these points in mind it would seem that in order to be proficient as an anaesthetist, core areas of education and development would involve: Social skills/communication, stress management, dispute resolution, leadership, humility, and professionalism.
But in reality, education in these areas during our training does not exist. Despite this, as I come to the end of my training, I feel reasonably well versed in all of the above areas. How, one might wonder, is this the case?
First of all it is important to define what the Hidden Curriculum means at a postgraduate level. It has been defined as “the unstated promotion and enforcement of certain behavioural patterns, professional standards and social beliefs while navigating a learning environment”2
Literature relating to the hidden curriculum in the speciality of Anaesthesia is sparse. It has been suggested the hidden curriculum is a by-product of situational learning, and can be described as what students learn outside of explicit teaching.3
A paper in 2011 exemplified the influence of the hidden curriculum in a theatre environment. Outbursts of anger initiated by senior members of a team were quickly replicated by more junior members 4
The presence and influence of the hidden curriculum has become a more recognised entity.
Over the following paragraphs I hope to explore why the hidden curriculum in Anaesthesia is predominantly a positive entity, with only one major negative:
Why is the hidden curriculum valuable in Anaesthesia training?
Anaesthesia training in Ireland is unlike any other training program. Unlike other programs (surgery/medicine/paediatrics etc) where yearly rotations involve working with one or maybe two different consultants, anaesthesia involves working closely with up to 30 different consultants every 6 months for a 6 year period.
I would argue that in order to function as an anaesthetic consultant in our health system, the attributes cited by Larsson and Holmstrom are essential1, with the vast majority of anaesthetic consultants being universally proficient in these areas. While working with these consultants, role-modelling teaches trainees via the hidden curriculum to embrace these non-technical skills.
With increased exposure to ‘Consultant educators’ comes more diverse subconscious teaching styles – more teaching via the hidden curriculum. Interactions with patients and colleagues are observed more frequently as trainees are paired with consultants more often and for longer periods. From a scientific view point, exposure to such a large number of ‘role-models’ can result in trainees being exposed to a more normally distributed range of attributes, with outliers therefore becoming the exception and not the rule. Emulation of these role models is then the result
Team work is an important component of anaesthesia practice. Unlike many other specialities trainees work very closely with anaesthetic and critical care nurses, along with other medical practitioners and depend on them for successful crises management. Each experience reinforces the importance of good and clear communication in time dependant emergency situations.
We are therefore trained via the hidden curriculum to exhibit an air of calmness in all situations, perform under immense pressure, act as mediators, lead teams in crisis situations……and then disappear back into the darkness.
The hidden curriculum may teach us all of these skills, but does it teach us coping mechanisms?
It is well documented that Anaesthesia as a career is one of the highest risk professions for burnout. It has the highest rates of suicide and prescription drug addiction among medical professionals 5. From these statistics it is clear that the qualities we acquire during our learning from the hidden curriculum enable us to function as highly proficient anaesthetists but fail to address the psychological repercussions of our working environment. The lack of psychological preparation for the aftermath of critical events leads to depression and burnout. How anaesthetists deal with the psychological impact of the job is often mislabelled as ‘resilience’. The admired approach is to “Just get on with it”, regardless of the impact of adverse clinical events.
A clinical handover at the end of each shift is mandatory, but the emotional handover is non-existent.
How can we improve education via the hidden curriculum?
Acceptance is the first step in the path to redemption. The hidden curriculum is currently under recognised in Anaesthesia. Disseminate of information in relation to the hidden curriculum among our colleagues to improve awareness of its existence is essential. Only then will they realise the impact of their actions and interactions on trainees.
Subconscious behavioural learning is part of evolution. It is how animals assimilate both social interactions and survival instincts from their parents. It is therefore logical to target education at consultants rather than trainees. This may be a more efficient approach as it is through their actions that trainees learn.
How can we address the negatives?
Openness and transparency in relation to the hidden curriculum and consequently the psychological impact of our speciality is important. Recognition of these will allow for fund allocation for training and education. Leadership and Professionalism courses would become mandatory, and stress management courses could be integrated into core training modules, to aid a balanced training experience. Formalising both coping mechanisms and upskilling in this critical area will encourage conversation among anaesthetists and will ultimately improve well-being.
Batman always had Alfred to mend his wounds…..we only have each other!
Hidden Curriculum, Leadership, Professionalism, Education, Communication
Conflict of Interest
Dr. Peter Moran
SpR in Anaesthesia
Department of Anaesthesia , University Hospital Galway, Ireland.
1. Larsson J, Holmström I. How excellent anaesthetists perform in the operating theatre—a qualitative study on non-technical skills. Br J Anaesth 2013 vol. 110 p.115-21
2. Miller, J. P., Seller, W. Curriculum, Perspectives and Practice. 1990. Ch 9, p. 205-209
3. Gaiser RR The teaching of professionalism during residency: why it is failing and a suggestion to improve its success. Anesth Analg 2009; 108: 948-54
4. Lingard L “Beyond Communication Skills”: Research in Team Communication and Implications for Surgical Education. Surg Educ 2011; 199-213
5. Swanson SP, Robers LJ, Chapman MD. Are anaesthetists prone to suicide? A review of rates and risk factors. Anaesth Intensive Care 2004 Aug;31(4):434-45