The ‘worthy’ patient: rethinking the ‘hidden curriculum’ in medical education

Abstract

This paper examines how physicians determine the quality and quantity of time to devote to each patient, and how these decisions are taught to physicians-in-training as part of the ‘hidden curriculum’ in medical education. The notion of moral economy is used to analyze how judgments of patient worth come to guide and influence interactions among physicians and physicians-in-training and patients, and how these interactions impact medical care. However, this paper also questions the notion of the hidden curriculum as a static or reified concept. Instead, the paper uses participant narratives to show how physicians-in-training are not simply passive recipients of the hidden curriculum but also actively resist judging patients based on perceptions of worth, even as they learn to operate within a moral economy of care.

Keywords:

• biomedicine
• medical anthropology
• ethnography
• moral economy

Acknowledgements

This research was made possible by a University of California, Berkeley Mentored Research Award [RH] and funds provided by the UCSF Department of Anthropology, History, and Social Medicine [RH and AT] and the UCSF Medical Scientist Training Program [AT]. The authors would like to thank Sharon Kaufman, Nancy Burke, and Brian Dolan for their comments on drafts of this paper, as well as the anonymous reviewers.

Conflict of interest: none.

Notes

1. The term ‘hidden curriculum’ was coined by Philip Jackson in 1968 to describe the attitudes and beliefs that children must learn as part of the socialization process in order to succeed in school. Hafferty was the first to adapt the concept to the area of medicine in 1994.

2. R. Higashi, an anthropologist, conducted all field research activities under the mentorship of three physicians (M. Steinman, C. B. Johnston, and M. Harper).