Frederic W. Hafferty

The hidden curriculum, ethics teaching, and the structure of medical education.

The authors raise questions regarding the wide-spread calls emanating from lay and medical audiences alike to intensify the formal teaching of ethics within the medical school curriculum. In particular, they challenge a prevailing belief within the culture of medicine that while it may be possible to teach information about ethics (e.g., skills in recognizing the presence of common ethical problems, skills in ethical reasoning, or improved understanding of the language and concepts of ethics), course material or even an entire curriculum can in no way decisively influence a students personality or ensure ethical conduct. To this end, several issues are explored, including whether medical ethics is best framed as a body of knowledge and skills or as part of ones professional identity. The authors argue that most of the critical determinants of physician identity operate not within the formal curriculum but in a more subtle, less officially recognized “hidden curriculum.” The overall process of medical education is presented as a form of moral training of which formal instruction in ethics constitutes only one small piece. Finally, the authors maintain that any attempt to develop a comprehensive ethics curriculum must acknowledge the broader cultural milieu within which that curriculum must function. In conclusion, they offer recommendations on how an ethics curriculum might be more fruitfully structured to become a seamless part of the training process.

Beyond Curriculum Reform: Confronting Medicine's Hidden Curriculum.

Throughout this century there have been many efforts to reform the medical curriculum. These efforts have largely been unsuccessful in producing fundamental changes in the training of medical students. The author challenges the traditional notion that changes to medical education are most appropriately made at the level of the curriculum, or the formal educational programs and instruction provided to students. Instead, he proposes that the medical school is best thought of as a “learning environment” and that reform initiatives must be undertaken with an eye to what students learn instead of what they are taught. This alternative framework distinguishes among three interrelated components of medical training: the formal curriculum, the informal curriculum, and the hidden curriculum. The author gives basic definitions of these concepts, and proposes that the hidden curriculum needs particular exploration. To uncover their institutions hidden curricula, he suggests that educators and administrators examine four areas: institutional policies, evaluation activities, resource-allocation decisions, and institutional “slang.” He also describes how accreditation standards and processes might be reformed. He concludes with three recommendations for moving beyond curriculum reform to reconstruct the overall learning environment of medical education, including how best to move forward with the Medical School Objectives Project sponsored by the AAMC.

Professional dynamics and the changing nature of medical work

The organization and delivery of health care in the United States is undergoing significant social, organizational, economic, political, and cultural changes with important implications for the future of medicine as a profession. This essay will draw upon some of these changes and briefly review major sociological writings on the nature of medicines professional status to examine the nature of professional dynamics in a changing environment. To this end, we focus on the nature of medical work and how this work impacts on and is impacted by medicines own internal differentiation and the presence of contested domains at medicines periphery. We trace this dynamic through a number of issues including the multidimensional nature of medical work, the role of elites in that work, and how changes in the terms and conditions of work can exert changes at medicines technical core. We close with some thoughts on the relationship of public policy to medicines professional status, the role health policy might take in shaping a new professional status, the role health policy might take in shaping a new professional ethnic for medicine, and the role sociologists might play in this process.

Into the valley : death and the socialization of medical students

A thematic and theoretical overview mercy hospital the anticipation of anatomy lab anatomy lab meeting ambiguous man the cadaver as a future self Mr. Kilwauski discussion. Appendix: comments of methodology.

Moving beyond nostalgia and motives: towards a complexity science view of medical professionalism.

Modern-day discourse on medical professionalism has largely been dominated by a “nostalgic” view, emphasizing individual motives and behaviors. Shaped by a defining conflict between commercialism and professionalism, this discourse has unfolded through a series of waves, the first four of which are discovery, definition, assessment, and institutionalization. They have unfolded in a series of highly interactive and overlapping sequences that extend into the present. The fifth wave—linking structure and agency—which is nascent, proposes to shift our focus on professionalism from changing individuals to modifying the underlying structural and environmental forces that shape social actors and actions. The sixth wave—complexity science—is more incubatory in nature and seeks to recast social actors, social structures, and environmental factors as interactive, adaptive, and interdependent. Moving towards such a framing is necessary if medicine is to effectively reestablish professionalism as a core principle.

The increasing complexities of professionalism.

Organized medicines modern-day professionalism movement has reached the quarter-century mark. In this article, the authors travel to an earlier time to examine the concept of profession within the work of Abraham Flexner. Although Flexner used the concept sparingly, it is clear that much of his writing on reforming medical education is grounded in his views on physicians as professionals and medicine as a profession. In the first half, the authors explore Flexners views of profession, which were (1) empirically (as opposed to philosophically) grounded, (2) case based and comparatively framed, (3) sociological in orientation, and (4) systems based, with professionalism conceptualized as dynamic, evolving, and multidimensional. In the second half, the authors build on Flexners systems perspective to introduce a complexity science understanding of professionalism. They define professionalism as a complex system, introduce a seven-part typology of professionalism, and explore how the organization of physician work and various flash points within medicine today reveal not one but several competing forms of professionalism at work. The authors then develop a tripartite model of professionalism with analysis at the micro, meso, and macro levels. They conclude with observations on how best to frame professionalism as a force for change in 21st-century medical education. Flexners reforms were grounded in his vision of two particular types of professional—the physician clinician and the full-time academic physician–scientist. The authors propose reform grounded in professionalism as a complex system composed of competing types.

The world as the new local clinic: A critical analysis of three discourses of global medical competency

The effects of globalization on health are the focus of administrators, educators, policy makers and researchers as they work to consider how best to train and regulate health professionals to practice in a globalized world. This study explores what happens to constructs such as medical competence when the context of medical practice is discursively expanded to include the whole world. An archive of texts was assembled (1970-2011) totaling 1100 items and analyzed using a governmentality approach. Texts were included that articulated rationales for pursuing global education activities, and/or that implicitly or explicitly took a position on medical competencies in relation to practicing medicine in international or culturally diverse contexts, or in dealing with health issues as global concerns. The analysis revealed three distinct visions, representative of a primarily western mentality, for preparing physicians to practice in a globalized world: the universal global physician, the culturally versed global physician and the global physician advocate. Each has its own epistemological relationship to globalization and is supported by an evidence base. All three discourses are active and productive, sometimes within the same context. However, the discourse of the universal global physician is currently the most established. The challenge to policy makers and educators in evolving regulatory frameworks and curricula that are current and relevant necessitates a better understanding of the socio-political effects of globalization on medical education, and the ethical, political, cultural and scientific issues underlying efforts to prepare students to practice competently in a globalized world.

A sociological framing of medicine's modern-day professionalism movement

There is a great deal to learn from Martimiakis et al.’s conscientious and insightful look at the Sociological Interpretations of Professionalism. If nothing else, we need to seriously consider the research and pedagogical implications of their conclusion that professionalism is a ‘distributed attribute’ and therefore, like competence, something that is best understood as a product of interaction embedded in ‘systemic considerations’ rather than as a reflection of individuals and their motives.

Pelvic laparotomy without an indwelling catheter: a retrospective review of 949 cases

A retrospective review of 949 cases of pelvic laparotomy without an indwelling catheter was conducted. Contrary to traditional beliefs, this study found that the use of an indwelling catheter was not necessary to assure either adequate exposure during operation or satisfactory voiding in the postoperative period. Various prophylactic steps included staff attention to the preoperative and postoperative voiding needs of patients and occasional bladder needling during operation. These efforts resulted in a low (22.1%) postoperative distress catheterization rate with no complications if needling was done. Urinary infection rates ranged from less than 1% for patients who did not require distress catheterization to 3.9% for a comparative population of patients who had an indwelling catheter during and after operation. Abstaining from the use of an indwelling catheter was also associated with lower cost and greater patient satisfaction.

Decontextualizing disability in the crime mystery genre: the case of the invisible handicap

ABSTRACT The depiction of physical impairments in popular culture reflects as well as shapes public attitudes towards persons with disabilities. Scholars have begun to document images of disabilities (the ‘what’) in venues such as literary fiction, motion pictures, advertisements, and television programming but there has been less attention directed toward exploring the techniques through which images are delivered (the ‘how’). In this paper we explore how the story telling devices of disability—in-dialogue versus disability-in-action and the endowment of characters with compensating characteristics are employed in one segment of popular culture—literary fiction, one genre within this class—the detective novel, and one type of physical impairment—the deaf detective. Our findings suggest that the use of these devices is historically rooted and how they transform handicaps and disabilities into physical impairments thus decontextualizing what is essentially a social issue into one that is ascribed to indivi...