Observations of the hidden curriculum on a paediatrics tertiary care clinical teaching unit.

Objective: The hidden curriculum is a set of influences that function at the level of organizational structure and culture which fall outside the formal curriculum, and are often unarticulated or unexplored. Learning associated with the hidden curriculum may have negative consequences on trainee educational development. The study goal was to examine how aspects of the hidden curriculum were enacted during ward rounds on a tertiary care general paediatrics clinical teaching unit (CTU).

Methods: We conducted an ethnographic case study on a CTU of a tertiary care paediatric hospital and observed interactions between medical students, residents and attending staff on rounds. Detailed field notes were collected and inductive analysis was used to inform descriptions and identify themes regarding the hidden curriculum.

Results: Twenty-two hours of observation were performed. Two major themes emerged: the hierarchical nature of team dynamics and engagement mediated by perceptions of relevance of the rotation. The hierarchical nature of team dynamics reflected the reinforcement of the rules of rank and 'who to respect'; it contained three subthemes including 'rules of the game', positioning and questioning order. Engagement mediated by perceptions of relevance of the rotation concerned the finding that active participation and attentiveness during rounds varied by home discipline.

Conclusions: We were able to identify representations of the hidden curriculum during observations on a tertiary care paediatric CTU. Interest appears to be a determinant in student level of engagement and observed hierarchies have the potential to impact this engagement either positively or negatively.