Trickle-Down Professionalism: Hidden Curriculum and the Pediatric Hospitalist

Abstract

The orthopedic surgeon was adamant that the Gram-positive cocci growing from the blood culture of a patient with hip pain represented a true infection and that the patient needed to be started on antibiotics. He told me this over the phone, and reiterated it to my team in no uncertain terms while I was out of the workroom. I was less convinced. The child had defervesced without treatment, and his inflammatory markers had remained low. The next day, when the culture was identified as coagulase-negative staph, and the child was discharged from the hospital without further intervention, I remarked to my team: “Surgeons are very concrete thinkers, who see the world in black and white. Hospitalists are abstract thinkers, who see the world in shades of gray.” I might as well have spouted off the old cliche: “Surgeons cut, but don’t think. Primary care physicians think, but don’t cut.” But inadvertently, I was telling my team something else: those who disagree with me are not worthy of my respect, and in so doing, I was indoctrinating them in a destructive verse of the “hidden curriculum” of medicine. The hidden curriculum is defined as those values that are primarily implicitly, rather than explicitly, learned in the workplace, and they typically deal with issues of professionalism, or, often, the lack thereof.1–3 Medical students pick up these ideas from day 1: physician knowledge is superior to nurse knowledge; those beneath you on the educational ladder can be treated with less respect than those above you; questioning a superior is a sign of disrespect; psychiatric patients bring their diseases on themselves and deserve …