Or What Trainees Learn Between Patients

How the Hidden Curriculum Shapes Physicians Beyond Formal Medical Training

Medical education is often defined by the moments that seem most memorable. We devote considerable attention to teaching diagnostic reasoning, communication skills, ethics, and evidence-based practice through carefully designed curricula. Trainees remember the first difficult diagnosis they make independently, the resuscitation that tests their composure, or the family meeting that reshapes their understanding of illness and healing. These experiences undoubtedly influence professional development. Yet I have come to believe that many of the lessons that ultimately define physicians are learned not during these extraordinary moments, but in the ordinary spaces between patient encounters.

Several months ago, after a busy day in the emergency department, a psychiatry resident and I walked back toward the workroom after completing another consultation. We had admitted several patients, managed multiple crises, and neither of us had stopped for lunch. As we sat down to finish our documentation, the resident hesitated before asking a question.

"How do you know when you've done enough?"

At first, I assumed the question referred to the patient we had just assessed.

It did not.

"I mean," the resident continued, "how do you know when you've done enough for the day?"

The question stayed with me long after the shift ended because it was not really about workload. It was about identity. The resident was trying to understand what kind of physician medicine expected them to become. Should a good doctor always stay later? Should every unfinished task feel like a personal failure? Was self-sacrifice simply part of professionalism? None of these questions appeared in the formal curriculum, yet they were central to learning how to practice medicine.

Understanding the Hidden Curriculum and Professional Identity Formation in Medicine

The hidden curriculum has long been recognized as one of the most influential forces in medical education. It consists of the implicit values, behaviours, and cultural norms that learners absorb through observation rather than formal teaching. While lectures may describe professionalism, compassion, and physician well-being, trainees often determine what is truly valued by watching how experienced physicians behave when no one is explicitly teaching. Hafferty described the hidden curriculum as the organizational influences that function beyond the formal curriculum and shape learners' values, behaviours, and professional identities in powerful but often unrecognized ways.¹

As psychiatrists and educators, we often underestimate the power of these seemingly ordinary moments. Trainees are constantly observing how we respond to uncertainty, interact with colleagues, recover from difficult encounters, and balance competing responsibilities. They notice whether we thank nurses after challenging shifts, whether we speak respectfully about patients who frustrate us, whether we apologize for taking vacation, and whether leaving work on time is viewed as responsible or as evidence of insufficient commitment. They notice whether we answer emails late into the evening because we choose to or because we believe we have no choice. They notice whether we ask colleagues how they are doing and whether we pause long enough to hear the answer. These observations gradually become their understanding of what it means to be a physician.

Professional identity is formed not only through acquiring knowledge and clinical competence but also through belonging to a community whose values are demonstrated every day. Cruess and colleagues argue that becoming a physician involves more than mastering competencies; it requires internalizing the values, behaviours, and responsibilities of the profession through observation, reflection, and participation within the clinical community.² Learners understandably assume that the behaviours they repeatedly observe are the behaviours that define successful physicians.

Physician Burnout and the Disconnect Between Wellness Education and Workplace Culture

This creates an important paradox. Over the past decade, medical education has invested significant effort in promoting physician wellness, resilience, and psychological health. Residency programs increasingly offer workshops on burnout prevention, mindfulness, and self-care. These initiatives are valuable and necessary. However, their impact is inevitably limited if the clinical environment teaches a different lesson. A one-hour seminar on wellness cannot compete with months of observing respected clinicians skip meals, apologize for taking vacation, or quietly describe chronic exhaustion as "part of the job."

Perhaps the greatest challenge facing the future physician workforce is not a lack of awareness regarding burnout. Most trainees recognize the risks of emotional exhaustion before they complete residency. Rather, the challenge lies in reconciling what they are taught with what they witness. If the formal curriculum encourages balance while the hidden curriculum rewards self-neglect, learners are left with little doubt about which message carries greater weight.

This disconnect has become increasingly relevant as medicine confronts growing administrative demands, workforce shortages, and the pressures of increasingly corporatized health care systems. Productivity metrics, documentation requirements, and expectations of efficiency have become unavoidable features of contemporary practice. Although these realities cannot be ignored, neither should they define the professional identities of future physicians. As West and colleagues have emphasized, meaningful improvements in physician well-being require organizational commitment in addition to individual resilience.³ If medicine measures success solely by productivity, it risks producing physicians who survive the system while gradually becoming disconnected from the very values that brought them into the profession.

Building a Healthier Physician Workforce Through Sustainable Medical Practice

Building a thriving physician workforce therefore requires more than wellness curricula or resilience training. It requires intentionally creating environments in which physicians are permitted to remain fully human. Flourishing is not achieved simply by teaching clinicians how to withstand adversity; it is fostered by developing cultures where compassion extends to colleagues as readily as it does to patients, where asking for help is viewed as insight rather than inadequacy, and where sustainable practice is considered an expression of professionalism rather than a departure from it.

The Power of Physician Role Modeling in Medical Education

Fortunately, the hidden curriculum is not immutable. Every clinician who works with learners possesses the ability to influence it, often through remarkably ordinary actions. When an attending physician openly acknowledges uncertainty, they demonstrate intellectual humility. When they encourage a resident to eat before returning to work, they communicate that personal well-being is compatible with excellent patient care. When they thank a nurse after a difficult shift, debrief an emotionally challenging consultation, or leave on time after completing their responsibilities without apology, they model a sustainable form of professionalism that learners are unlikely to forget. Role modelling has consistently been recognized as one of the most influential educational strategies in medicine because learners remember what educators do as much as what they say.⁴

As psychiatrists, we may be particularly well positioned to recognize these dynamics. Our discipline emphasizes that human behaviour is shaped not only by explicit instruction but also by relationships, environments, and repeated experiences. We understand that small interactions accumulate over time to influence identity, coping, and resilience. The same principle applies to medical education. The culture we create within clinical workplaces becomes part of every learner's education, whether we acknowledge it or not.

I have often reflected on the resident's question since that afternoon.

Medicine rarely tells us when we have done enough.

Instead, it continually invites us to decide what kind of physician we hope to become.

That decision is shaped less by the lectures we attend than by the people we observe every day.

Transforming Medical Education to Support the Next Generation of Physicians

If we hope to improve the professional experience of today's physicians while preparing tomorrow's workforce to meet increasingly complex health care challenges, we must broaden our understanding of medical education. Formal curricula will always remain essential, but they are only part of the story. Every interaction with a colleague, every response to uncertainty, every expression of gratitude, every respectful conversation after a difficult patient encounter, and every healthy boundary communicated without apology becomes part of the education of those around us. Professional identity is formed through these countless everyday experiences that communicate what our profession truly values.²˒⁵

If we hope to build a thriving physician workforce for the future, we must recognize that every clinical day is also a day of teaching. The physicians of tomorrow are shaped not only by the curriculum we design but also by the culture we create. Long after they forget our lectures, they will remember how we treated our patients, our colleagues, and ourselves. Perhaps the most enduring lesson we teach is not found in what we say, but in how we choose to practice medicine when no one realizes they are watching.

References

1. Hafferty FW. Beyond curriculum reform: confronting medicine's hidden curriculum. Acad Med. 1998;73(4):403-407.
2. Cruess RL, Cruess SR, Steinert Y. Amending Miller's pyramid to include professional identity formation. Acad Med. 2016;91(2):180-185.
3. West CP, Dyrbye LN, Shanafelt TD. Physician burnout: contributors, consequences and solutions. J Intern Med. 2018;283(6):516-529.
4. Passi V, Johnson N. The impact of positive doctor role modeling. Med Teach. 2016;38(11):1139-1145.
5. Wald HS. Professional identity formation in medical education for humanistic, resilient physicians: pedagogic strategies for bridging theory to practice. Acad Med. 2015;90(6):701-706

Devina Maya Wadhwa, MD, FRCPC is a psychiatrist practicing in Northern Ontario, Canada, and an Assistant Professor at NOSM University.