Learning professionalism through hidden curriculum: Iranian medical students’ perspective

  • Sajjad Azmand PhD Candidate of Medical Ethics Department of Medical Ethics, Shiraz University of Medical Sciences, Shiraz, Iran
  • Sedigheh Ebrahimi Associate Professor Department of Medical Ethics, Shiraz University of Medical Sciences, Shiraz, Iran.
  • Mohammadtaghi Iman Professor Department of Sociology, Shiraz University, Shiraz, Iran.
  • Omid Asemani Assistant Professor Department of Medical Ethics, Shiraz University of Medical Sciences, Shiraz, Iran.
Hidden curriculum, Professionalism, Undergraduate medical student, Content analysis, In-depth interview


Learning professionalism is a central topic in medical education. While many factors could affect the educational process of professionalism, hidden curriculum is considered one of the most important ones. As the working components of a hidden curriculum might be specific to the settings, this study explored its components in terms of professionalism and ethical conduct from the viewpoint of Iranian undergraduate medical trainees.

Semi-structured and in-depth interviews were used to collect medical students' experiences and viewpoints, which were then analyzed through simple content analysis and the codes and categories were extracted. Finally, themes were derived as the central organizing concepts.

Saturation occurred after 17 interviews. Seven main themes were extracted as the working components of hidden curriculum regarding professionalism in the setting: ‘convenient patients’, ‘evaluate me’, ‘trust as the base of team interactions’, ‘perceiving encouragement’, ‘relationship satisfaction and authenticity’, ‘workload and students’ well-being’ and ‘role modeling at the heart of professionalism’.

Students' perception and experiences are a rich source of gaining a deeper understanding of the working hidden curriculum. In this study, two groups of human-related and environment-related elements were extracted. They were effective in the formation of the current 'ethical climate', which shaped the professional and ethical identity of medical trainees. Moreover, specific plans regarding the condition of the settings may provide opportunities for medical educators to enhance professionalism in their institutions.

Author Biography

Omid Asemani, Assistant Professor Department of Medical Ethics, Shiraz University of Medical Sciences, Shiraz, Iran.




Glicken AD, Merenstein GB. Addressing the hidden curriculum: understanding educator professionalism. Med Teach. 2007; 29(1): 54-7.

Branch WT. The road to professionalism: reflective practice and reflective learning. Patient Educ Couns. 2010; 80(3): 327-32.

Swing SR. The ACGME outcome project: retrospective and prospective. Med Teach. 2007; 29(7): 648-54.

Rezaee R, Ebrahimi S. Clinical learning environment at Shiraz medical school. Acta Med Iran. 2013; 51(1): 62-5.

Chuang AW, Nuthalapaty FS, Casey PM, et al. To the point: reviews in medical education—taking control of the hidden curriculum. Am J Obstet Gynecol. 2010; 203(4): 316.e1-6.

Mossop L, Dennick R, Hammond R, Robbé I. Analysing the hidden curriculum: use of a cultural web. Medical Educ. 2013; 47(2):134-43.

Murakami M, Kawabata H, Maezawa M. The perception of the hidden curriculum on medical education: an exploratory study. Asia Pac Fam Med. 2009; 8(1):9.

Lempp H, Seale C. The hidden curriculum in undergraduate medical education: qualitative study of medical students' perceptions of teaching. BMJ. 2004; 329:770.

Hafferty FW, Franks R. The hidden curriculum, ethics teaching, and the structure of medical education. Academic Med. 1994; 69(11): 861-71.

Hafferty FW, O'Donnell JF. The hidden curriculum in health professional education. J Chiropr Educ. 2016; 30(1): 48–9.

Karnieli-Miller O, Vu TR, Holtman MC, Clyman SG, Inui TS. Medical students' professionalism narratives: a window on the informal and hidden curriculum. Acad Med. 2010; 85(1):124-33.

Ozolins I, Hall H, Peterson R. The student voice: recognising the hidden and informal curriculum in medicine. Med Teach. 2008; 30(6): 606-11.

Lawrence C, Mhlaba T, Stewart KA, Moletsane R, Gaede B, Moshabela M. The Hidden Curricula of Medical Education: A Scoping Review. Acad Med 2017. doi: 10.1097/ACM.0000000000002004.

Martimianakis MAT, Michalec B, Lam J, Cartmill C, Taylor JS, Hafferty FW. Humanism, the hidden curriculum, and educational reform: a scoping review and thematic analysis. Acad Med. 2015; 90(11Suppl): S5-S13.

Michalec B. The pursuit of medical knowledge and the potential consequences of the hidden curriculum. Health. 2011; 16(3):267-81.

Hill E, Bowman K, Stalmeijer R, Hart J. You've got to know the rules to play the game: how medical students negotiate the hidden curriculum of surgical careers. Med Educ. 2014; 48(9): 884-94.

Higashi RT, Tillack A, Steinman MA, Johnston CB, Harper GM. The ‘worthy’patient: rethinking the ‘hidden curriculum’in medical education. Anthropol Med. 2013; 20(1):13-23.

Hafler JP, Ownby AR, Thompson BM, et al. Decoding the learning environment of medical education: a hidden curriculum perspective for faculty development. Acad Med. 2011; 86(4): 440-4.

Gupta M, Forlini C, Lenton K, Duchen R, Lohfeld L. The Hidden ethics curriculum in two canadian psychiatry residency programs: a qualitative study. Acad Psychiatry. 2016; 40(4): 592-9.

Gaufberg EH, Batalden M, Sands R, Bell SK. The hidden curriculum: what can we learn from third-year medical student narrative reflections? Acad Med. 2010; 85(11): 1709-16.

Doja A, Bould MD, Clarkin C, Eady K, Sutherland S, Writer H. The hidden and informal curriculum across the continuum of training: a cross-sectional qualitative study. Med Teach. 2016; 38(4): 410-8.

Haidet P, Kelly PA, Chou C. Characterizing the patient-centeredness of hidden curricula in medical schools: development and validation of a new measure. Acad Med. 2005; 80(1): 44-50.

Browning DM, Meyer EC, Truog RD, Solomon MZ. Difficult conversations in health care: cultivating relational learning to address the hidden curriculum. Acad Med2007; 82(9):905-13.

Phillips SP, Clarke M. More than an education: the hidden curriculum, professional attitudes and career choice. Medl Educ. 2012; 46(9): 887-93.

Cruess SR, Cruess RL, Steinert Y. Role modelling—making the most of a powerful teaching strategy. BMJ. 2008; 336: 718.

Passi V, Johnson N. The hidden process of positive doctor role modelling. Med Teach. 2016; 38(7): 700-7.

Lamiani G, Leone D, Meyer EC, Moja EA. How Italian students learn to become physicians: a qualitative study of the hidden curriculum. Med Teach. 2011; 33(12): 989-96.

Bandini J, Mitchell C, Epstein-Peterson ZD, Amobi A, Cahill J, Peteet J, et al. Student and faculty reflections of the hidden curriculum.Am J Hosp Palliat Care. 2017; 34(1): 57-63.

Grbich C. Qualitative Data Analysis: an Introduction, 2nd ed. India: Sage Publication; 2012.

Guba EG. Criteria for assessing the trustworthiness of naturalistic inquiries. Educ Tech Res Develop. 1981; 29(2): 75-91.

D’eon M, Lear N, Turner M, Jones C. Perils of the hidden curriculum revisited. Med Teach. 2007; 29(4): 295-6.

Hafferty FW. Beyond curriculum reform: confronting medicine's hidden curriculum. Acad Med. 1998; 73(4): 403-7.

Michalec B, Hafferty FW. Stunting professionalism: The potency and durability of the hidden curriculum within medical education. Social Theory & Health. 2013; 11(4): 388-406.

Elzubeir MA, Rizk DE. Identifying characteristics that students, interns and residents look for in their role models. Med Educ. 2001; 35(3): 272-7.

Wright S. Examining what residents look for in their role models. Acad Med. 1996; 71(3): 290-2.

Wright SM, Carrese JA. Excellence in role modelling: insight and perspectives from the pros. CMAJ. 2002; 167(6): 638-43.

Fromme HB, Bhansali P, Singhal G, Yudkowsky R, Humphrey H, Harris I. The qualities and skills of exemplary pediatric hospitalist educators: a qualitative study. Acad Med. 2010; 85(12): 1905-13.

Wyber R, Egan T. For better or worse: role models for New Zealand house officers. N Z Med J. 2007; 120(1253): U2518.

Park J, Woodrow SI, Reznick RK, Beales J, MacRae HM. Observation, reflection, and reinforcement: surgery faculty members' and residents' perceptions of how they learned professionalism. Acad Med. 2010; 85(1):134-9.

Yazigi A, Nasr M, Sleilaty G, Nemr E. Clinical teachers as role models: perceptions of interns and residents in a Lebanese medical school. Med Educ. 2006; 40(7): 654-61.

Fantahun A, Demessie A, Gebrekirstos K, Zemene A, Yetayeh G. A cross sectional study on factors influencing professionalism in nursing among nurses in Mekelle Public Hospitals, North Ethiopia, 2012. BMC Nurs. 2014; 13:10.

Ratanawongsa N, Bolen S, Howell EE, Kern DE, Sisson SD, Larriviere D. Residents' perceptions of professionalism in training and practice: barriers, promoters, and duty hour requirements. J Gen Intern Med. 2006; 21(7): 758-63.

Shanafelt TD, Bradley KA, Wipf JE, Back AL. Burnout and self-reported patient care in an internal medicine residency program. Ann Intern Med. 2002; 136(5): 358-67.

Saipanish R. Stress among medical students in a Thai medical school. Med Teach. 2003; 25(5): 502-6.

Wallace JE, Lemaire JB, Ghali WA. Physician wellness: a missing quality indicator. Lancet. 2009; 374(9702): 1714-21.

Levine AC, Adusumilli J, Landrigan CP. Effects of reducing or eliminating resident work shifts over 16 hours: a systematic review. Sleep. 2010; 33(8): 1043-53.

Ayas NT, Barger LK, Cade BE, et al. Extended work duration and the risk of self-reported percutaneous injuries in interns. JAMA. 2006; 296(9): 1055-62.

Reed DA, Levine RB, Miller RG, et al. Effect of residency duty-hour limits: views of key clinical faculty. Arch Intern Med. 2007; 167(14): 1487-92.

Kalantari M, Kamali M, Joolaee S, Shafarodi N, Rassafiani M. Factors affecting ethical behavior in pediatric occupational therapy: A qualitative study. Med J Islam Repub Iran. 2015; 29: 282.

Martini S, Arfken CL, Balon R. Comparison of burnout among medical residents before and after the implementation of work hours limits. Acad Psychiatry. 2006; 30(4): 352-5.

Tzeng H-M. Satisfying nurses on job factors they care about: A Taiwanese perspective. J Nurs Adm. 2002; 32(6): 306-9.

Asemani O, Iman MT, Moattari M, Tabei SZ, Sharif F, Khayyer M. An exploratory study on the elements that might affect medical students' and residents' responsibility during clinical training. J Med Ethics Hist Med. 2014; 7: 8.

Utkualp N. Ethical issues and dilemmas encountered in nursing practice in Turkey. International Journal of Caring Sciences. 2015; 8(3): 830.

Ashar A, Ahmad A. Developing professionalism: dental students’ perspective. Journal of the College of Physicians and Surgeons Pakistan. 2014; 24(12): 902-7.

Hundert EM, Hafferty F, Christakis D. Characteristics of the informal curriculum and trainees' ethical choices. Acad Med. 1996; 71(6): 624-42.

How to Cite
Azmand S, Ebrahimi S, Iman M, Asemani O. Learning professionalism through hidden curriculum: Iranian medical students’ perspective. J Med Ethics Hist Med. 11.
Original Article(s)