Put yourself in this situation: You’re an anesthesia resident, and a staff anesthesiologist in the operating room asks you to give blood to a patient who is a Jehovah’s Witness. The patient has explicitly stated that receiving blood is against his or her beliefs. What do you do?

A new study published in the March issue of the Canadian Journal of Anesthesia put real anesthesia residents in this simulated scenario and found that the majority of trainees in the two groups that underwent the simulation gave blood to the “patient.” Despite knowing the patient’s religious beliefs did not allow the patient to receive a blood transfusion, the trainees felt the need to listen to their attending physician.

After the simulation, participants shared their thoughts about why they went through with the transfusion. Many residents discussed the hierarchical influences in the operating room, often characterized by fear or intimidation. Few residents in the simulation managed to effectively challenge the inappropriate care, perceiving this as a devaluation of their role within the care team.

“The hierarchy is well established with the surgical staff,” one resident said in the study, which took place at two Ontario universities. “I think they pride themselves on sort of abusing the junior residents.”

The study also highlighted the culture of the operating room—a space with obstacles or boundaries that must be respected, though these boundaries may not be made explicit. For example, a single anesthesiology consultant might have a different way of handling the management of each case, and residents are expected to anticipate these differentiations.

Revealing the hidden curricula

These findings bolster discussions about the “hidden curricula”—subtle structural issues within an institution that shape how and what trainees are taught. These are the lessons residents learn that were never explicitly intended and may be contrary to the formal curriculum, according to Frederic W. Hafferty, PhD, associate dean of professionalism at the Mayo Medical School and associate director of the program on professionalism and ethics at the Mayo Clinic.

“We live in a world organized around, and driven by, other-than-formal rules,” Dr. Hafferty said. “Medical trainees come to us already conditioned to pay close attention to the other-than-formal rules and to have their lives organized and dictated by these structures.”

Residents in the Canadian simulations spoke about their experiences with the hidden curricula.

“You learn through shock and trauma, so when you’re yelled at, you never forget,” one resident said in the study. “For the most part, you don’t tend to remember the people who are lax, but the people are strict … [and] you make sure that you do it their way.”

Taking action

The Canadian study suggests residency programs should focus on formal curricula to provide residents with the competencies necessary to challenge staff management decisions in a clear and effective manner, especially when patient safety is at risk.

However, the study acknowledges that “institutional and professional cultures are much harder to change than individual competencies.”

“Delivering an effective curriculum [is] not just about deciding what to teach and what they should learn,” Dr. Hafferty said. “It’s about deciding what to do in the context of everything going on in learning environment.”

Tell us: What are your experiences with the “hidden curricula”? Share your thoughts in a comment below or on the AMA Resident and Fellow Facebook page.

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