Implicit Bias, the Hidden Curriculum and the Impact on Medical Education

By R. Michelle Tyner, MS, Direction, Education Strategy at ArcheMedX Inc.

Alliance National Learning Competency

Competency Area 2: Designing Educational Interventions

Competency Area 7: Engage in Self-Assessment and Lifelong Learning

Bias comes in many forms in many environments. Biases based on gender, race, appearance and socioeconomic status are among the most common, and, for decades, these biases have been well documented within the education system. For example, from an early age, girls and boys are taught differently. While often inadvertent, these differences have created a significant deficit in self-confidence in math and sciences in girls as young as 6 years old.1 Understanding bias is a critical first step in beginning to lessen the impact on these target populations and leveling the playing field.

Two primary forms of bias exist: explicit and implicit. Explicit biases, which are those attitudes and beliefs that we hold at a conscious level, tend to appear when we feel threatened and insecure — often revealing the worst of are more challenging to mitigate because we are unlikely to be aware of them as they affect our thinking and decision making. One example of an implicit bias might be a deep-seated expectation that men are better leaders or women are more emotional and therefore less rational. In reality, were we to think about each statement, we know that these stereotypes are not indicative of an entire group or population.

Medical education is not exempt from the consequences of bias. Historically, medical education has been patriarchal — an education system for men created by men. With the passing of Title IX2 and changes in societal expectations, the number of women in medical school increased and, currently, there is parity in the number of female and male medical students. However, parity in numbers does not mean equity in educational experience. In as much as medical training is the culmination of nearly 20 years of indoctrination, by the time a student completes medical school, the educational journey of male clinicians may have been vastly different from that of female clinicians. This may lead one to wonder whether (or how) the institutes and faculty of medical education might address this.

The answer to that question is not a simple one. Medical education can be thought of as including three distinct curricula: the formal curriculum, an informal curriculum and the hidden curriculum. The formal curriculum includes the stated and endorsed curriculum; the informal curriculum includes the interpersonal teaching that happens between the faculty and the students3; and the hidden curriculum includes the biases that have become ingrained within the organization, passed down from generation to generation. First described by Hafferty in 19944, the overall culture of the organization is a major contributing factor when trying to reduce or eliminate implicit bias. In the end, efforts to revise the formal and informal curricula will have little impact on equity if the hidden curriculum remains hidden.

Importantly, not all parts of the hidden curriculum are bad. For example, the hidden curriculum may support the formation of a trainee’s professional identity or an organization’s culture. However, when it comes to the negative biases within the hidden curriculum, they often have impacts that may persist generationally. Interns learn from residents, residents learn from fellows and fellows learn from attending. With each step in this process, the teacher may pass on both knowledge and biases. And, therefore, the patriarchal bias of medical education becomes so extremely difficult to change. How many times have we heard, “we have always done it this way.” Now consider that “this way” often includes the generational reinforcement of implicit biases.

How do you begin to mitigate the bias without creating additional biases along the way? The first step is to be an example. Do you know what your implicit biases are? Take a minute and take the Implicit Associations Test (IAT), which can be found here: https://implicit.harvard.edu/implicit/takeatest.html.  In addition to understanding your biases, have your peers take the test as well. They do not have to share the results, but knowledge is power. The next important step is to watch your language. This is far more difficult than it sounds. But remember that if you are not choosing your words intentionally, you are choosing your words unintentionally. For example, “you guys” is an exclusionary phrase. A more inclusive phrase would be “everyone” or “team.” Another example would be replacing “attendees and their wives” by simply saying “attendees and their guests.”

Biases, both explicit and implicit, are natural. However, when they have a negative effect on discrete groups of people, they must be identified and corrected. Hopefully this brief overview provides you a greater understanding and awareness of biases in medical education. The first step is being part of the solution. By recognizing personal biases and making efforts to mitigate their impact in your educational programs, you are taking one positive step in what will undoubtedly be a long, but invaluable journey.

References

  1. Cimpian A, Leslie S-J. Why Young Girls Don’t Think They Are Smart Enough. New York Times January 26, 2017.
  2. Title IX, Education Amendments of 1972. Title IX. Vol Title 20 U.S.C. Sections 1681-16881972.
  3. Hafferty FW. Beyond curriculum reform: confronting medicine’s hidden curriculum. Academic medicine: journal of the Association of American Medical Colleges. 1998;73(4):403-407.
  4. Hafferty FW, Franks R. The hidden curriculum, ethics teaching, and the structure of medical education. Academic medicine: journal of the Association of American Medical Colleges. 1994;69(11):861-871.

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