Lining up the ducks: aligning the hidden, formal and informal curricula in an immersed learning environment
Keywords:medical education, Aboriginal health, hidden curriculum
Introduction: Incongruence between the formal, informal and hidden curricula of Aboriginal and Torres Strait Islander health education is a barrier to student learning and preparedness for delivering effective and culturally-safe healthcare to Aboriginal people. We investigated the impact of student and registrar immersion experiences in an urban Aboriginal and Torres Strait Islander primary healthcare service, where greater alignmentbetween the formal, informal and hidden curricula is evident.
Methods: In 2014, 11 students and registrars participated in this qualitative study. At the commencement of their placement, they received a project-specific vignette describing a 46-year-old Aboriginal woman with type 2 diabetes, wrote responses to questions about her clinical care and participated in a semi-structured interview, which explored the assumptions underpinning their responses. Post-placement, participants reflected on their earlier responses and what they had learned from their placement about Aboriginal and Torres Strait Islander people and their health and healthcare.
Results: The placement negated many of the students’ and registrars’ previously held assumptions about Aboriginal people, for example, that Aboriginal people don’t care about their health and will not engage with health professionals. Participants became aware of the benefits of long-term doctor–patient relationships based on trust and respect. Participants realised that doctors have a role in addressing social determinants of health.
Conclusions: Our participants’ shifts in thinking and knowing suggest that greater alignment between the formal, informal and hidden curricula can lead to deepened and more effective learning outcomes for medical students and registrars and, critically, to improved Aboriginal health outcomes. Identification and reproduction of the key elements of Aboriginal health services may enrich medical students’ learning about culturally-safe and appropriate care for Aboriginal people.
Askew, D., Paul, D., & Ewen, S. (2017). Shifting understandings: Do scenario-based clinical decisions change with immersion? In the Lime Network (Ed.), Good practice case studies (Vol. 4). Melbourne, Australia: The University of Melbourne.
Australian Medical Council. (2012). Standards for assessment and accreditation of primary medical programs by the Australian Medical Council 2012. Retrieved from http://www.amc.org.au/files/d0ffcecda9608cf49c66c93a79a4ad549638bea0_ original.pdf
Beagan, B. L. (2003). Teaching social and cultural awareness to medical students: “It's all very nice to talk about it in theory, but ultimately it makes no difference”. Academic Medicine, 78(6), 605–614.
Bond, C., Foley, W., & Askew, D. (2016). "It puts a human face on the researched": Qualitative evaluation of an Indigenous health research governance model. Australian and New Zealand Journal of Public Health, 40(Suppl. 1), S89–S95. doi:10.1111/1753-6405.12422
Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3(2), 77–101. doi:10.1191/1478088706qp063oa
Brough, M., Bond, C., & Hunt, J. (2004). Strong in the city: Towards a strengths- based approach in Indigenous health promotion. Health Promotion Journal of Australia, 15(3), 215–220. doi:10.1071/HE04215
Burgess, D. J., Fu, S. S., & van Ryn, M. (2004). Why do providers contribute to disparities and what can be done about it? Journal of General Internal Medicine, 19(11), 1154–1159. doi:10.1111/j.1525-1497.2004.30227.x
Carson, B., Dunbar, T., Chenhall, R., & Bailie, R. (Ed.). (2007). Social determinants of Indigenous health. Sydney, Australia: Allen & Unwin.
Cass, A., Lowell, A., Christie, M., Snelling, P. L., Flack, M., Marrnganyin, B., & Brown, I. (2002). Sharing the true stories: Improving communication between Aboriginal patients and healthcare workers. The Medical Journal of Australia, 176(10), 466–470.
Cooper, L. A., Beach, M. C., Johnson, R. L., & Inui, T. S. (2006). Delving below the surface: Understanding how race and ethnicity influence relationships in health care. Journal of General Internal Medicine, 21(Suppl. 1), S21–S27. doi:10.1111/ j.1525-1497.2006.00305.x
Dovidio, J. F., & Fiske, S. T. (2012). Under the radar: How unexamined biases in decision-making processes in clinical interactions can contribute to health care disparities. American Journal of Public Health, 102(5), 945–952.
Ewen, S., Barrett, J., Paul, D., Askew, D., Webb, G., & Wilkin, A. (2015). When a patient's ethnicity is declared, medical students' decision-making processes are affected. Internal Medicine Journal, 45(8), 805–812. doi:10.1111/imj.12800
Ewen, S., Mazel, O., & Knoche, D. (2012). Exposing the hidden curriculum influencing medical education on the health of Indigenous people in Australia and New Zealand: The role of the Critical Reflection Tool. Academic Medicine, 87(2), 200–205. doi:10.1097/ACM.0b013e31823fd777
Hafferty, F. W. (1998). Beyond curriculum reform: Confronting medicine's hidden curriculum. Academic Medicine, 73(4), 403–407.
Hafferty, F. W., Gaufberg, E. H., & O'Donnell, J. F. (2015). The role of the hidden curriculum in "on doctoring" courses. AMA Journal of Ethics, 17(2), 130–139. doi:10.1001/virtualmentor.2015.17.02.medu1-1502
Hayman, N. E., Askew, D. A., & Spurling, G. K. (2014). From vision to reality: A centre of excellence for Aboriginal and Torres Strait Islander primary health care. The Medical Journal of Australia, 200(11), 623–624.
Hayman, N. E., White, N. E., & Spurling, G. K. (2009). Improving Indigenous patients' access to mainstream health services: The Inala experience. The Medical Journal of Australia, 190(10), 604–606.
Kelaher, M. A., Ferdinand, A. S., & Paradies, Y. (2014). Experiencing racism in health care: The mental health impacts for Victorian Aboriginal communities. The Medical Journal of Australia, 201(1), 44–47.
Kirmayer, L. J. (2013). Embracing uncertainty as a path to competence: Cultural safety, empathy, and alterity in clinical training. Culture, Medicine, and Psychiatry, 37(2), 365–372. doi:10.1007/s11013-013-9314-2
Lacey, C., Huria, T., Beckert, L., Gilles, M., & Pitama, S. (2011). The Hui Process: A framework to enhance the doctor–patient relationship with Maori. The New Zealand Medical Journal, 124(1347), 72–78.
Marley, J. V., Moore, S., Fitzclarence, C., Warr, K., & Atkinson, D. (2014). Peritoneal dialysis outcomes of Indigenous Australian patients of remote Kimberley origin. Australian Journal of Rural Health, 22(3), 101–108. doi:10.1111/ajr.12086
Milroy, H. (n.d.). The dance of life. Retrieved from https://www.ranzcp.org/ Publications/Indigenous-mental-health/Aboriginal-Torres-Strait-Islander-mental- health/The-Dance-of-Life.aspx
O'Donnell, J. F. (2015). Introduction: The hidden curriculum—a focus on learning and closing the gap. In F. W. Hafferty, J. F. O'Donnell, & D. C. Baldwin (Eds.), The hidden curriculum in health professional education. Hanover, NH: Dartmouth College Press.
Paul, D., Ewen, S. C., & Jones, R. (2014). Cultural competence in medical education: Aligning the formal, informal and hidden curricula. Advances in Health Sciences Education: Theory and Practice, 19(5), 751–758. doi:10.1007/s10459-014- 9497-5
Paul, D., Hill, S., & Ewen, S. (2012). Revealing the (in)competency of "cultural competency" in medical education. AlterNative, 8(3), 318–328.
Saha, S., Beach, M. C., & Cooper, L. A. (2008). Patient centeredness, cultural competence and healthcare quality. Journal of the National Medical Association, 100 (11), 1275–1285.
How to Cite
On acceptance for publication in FoHPE the copyright of the manuscript is signed over to ANZAHPE, the publisher of FoHPE.
Any reproduction of material published in FoHPE must have the express permission of the publisher.
Articles published in Focus on Health Professional Education (FoHPE) are available under Creative Commons Attribution Non-Commercial No Derivatives Licence (CC BY-NC-ND 4.0).