By Prof. Pamela Zarkowski, Provost and Vice President for Academic Affairs, University of Detroit Mercy
An environmental scan of dental education programs would identify a number of activities that emphasize integrity, professionalism and ethically based decision-making and patient care. At some schools, ethics and professionalism are woven into the tapestry of student experiences starting with an admissions process that asks candidates to analyze an ethical scenario. At many more institutions, students and faculty often participate in a white coat or similar ceremony, during which a public oath is recited by incoming students committing themselves to address the needs of the patients and the communities they will serve. As students’ educational experiences progress, their schools’ curricula may emphasize ethics, values and professional obligations in interactions with classmates, faculty, staff, patients and community partners. And, as students graduate and join the ranks of their esteemed profession, they may again be reminded of their responsibility to continue to honor their obligations.
Academic dental programs throughout North America should be applauded for their efforts. The practices I’ve listed are both necessary and commendable, yet they are not sufficient to achieve our goals. In order to encourage an academic culture in which ethics is integral to the educational experience, we must shift the spotlight from its focus on students’ behavior and cast its light on a less visible contributor to their professional development: the hidden curriculum.
The hidden curriculum comprises the secondary set of messages that influence students’ professional development and decision-making. Simply stated, every academic dental program requires students to meet specific standards and follow policies, procedures or patterns of practice, but often students receive contradictory messages through what they observe, hear or experience. The literature identifies the faculty as those who usually deliver these messages—inadvertently or even with the best of intentions—but these contradictory or mixed messages have the potential to undermine a program’s efforts to encourage ethical and professional behavior.
Examples of the hidden curriculum abound. Take the expectation that students justify their clinical decisions based on scientific evidence. If a faculty member provides clinical guidance that is out-of-date and not supported by the evidence, students will experience a disconnect. This can lead to confusion or to misinterpreting previously laid out expectations.
Similarly, students are expected to attend all classes and purchase required texts, but students quickly learn that their professors view some courses as more important than others. As a result, students skip certain lectures, cut corners in preparing for exams and purchase only those texts that faculty refer to during class, even if the assigned materials contain important information that students should learn.
Students are also expected to arrive at clinic on time and treat their colleagues and patients with respect. But what might students learn from a faculty member who arrives late, leaves early or shows a lapse of professional conduct on the clinic floor? These unprofessional behaviors could undercut the messages about ethics and professionalism that we are working hard to convey to students in the official curriculum.
The hidden curriculum can have an even more pervasive influence on student attitudes toward the learning environment. As more institutions embrace a “student-centered” environment, faculty—especially in the preclinical and clinical settings—need to adjust their attention to focus more on student needs and behaviors. When a faculty member checks a cell phone or converses socially with a colleague in these educational settings, students may feel uncomfortable asking for assistance. This can be particularly troubling to students who are struggling.
What can we do to reveal the hidden curriculum and make our colleagues who exhibit unprofessional conduct aware of the impact of their behaviors on students and others? Faculty mentoring may be one solution, with peers providing feedback and suggestions about institutional expectations. We should also make sure that everyone—faculty, staff and administrators—are educated about their roles and responsibilities, and that all community members—not just students—are held accountable for their behavior.
We can also use the hidden curriculum to create some teachable moments. One powerful opportunity occurs when students encounter a patient who has been referred to the school clinic after receiving substandard care from someone in the private-practice community. Under these circumstances, patients sometimes question why they need to be retreated. Faculty can use these opportunities to model ways to address challenging professional situations. Faculty who respond well when ethical and professional situations arise can help create an environment that encourages students to respectfully question the mixed messages they receive.
At the institutional level, sensitivity to and recognition of the hidden messages that are delivered, intentionally or unintentionally, is a critical first step. A thoughtful and careful analysis of policies and procedures and the hidden messages that undermine them can be gathered from faculty, staff and students. Once those messages are identified, a school-wide code of conduct that includes consequences for all noncompliant behaviors can be developed. Continuing education, staff development programs and a willingness to revise policies and procedures as necessary can also contribute to fostering a culture of integrity, as can encouraging faculty to participate in meetings of the Student Professionalism and Ethics Association in Dentistry. Full- and part-time faculty and staff must be included in these activities.
The hidden curriculum clouds the ethics and professionalism environment at our schools, undermines the stated goals of our academic programs and may contribute to poor judgment or ethical lapses on the part of students. An environment that supports the modeling of ethical behaviors and integrity must be championed, practiced and reinforced at all levels. Teaching ethics and professionalism cannot be only about “us” (faculty, staff and administrators) looking at “them” (the students). Any effort in this regard that does not consider what students observe, hear and experience in actual practice will not be successful.