Uncovering the Hidden Curriculum of Global Health Electives

The hidden curriculum has been defined as the cultural values that are implicitly taught and learned in medical education.1 It has been suggested that most of the values, attitudes, beliefs, and related behaviors that medical students internalize are learned in the hidden curriculum as opposed to the formal curriculum.1 We believe that this original definition of hidden curriculum applies not only to medical students but also to postgraduate trainees, and even to fully trained specialists seeking additional experience. Recent criticism of global health electives (GHEs) and medical missions has called into question the values underlying these activities.2,3 As a result, there has been a movement toward formalizing and making explicit the values of equitable partnership and collaboration.4,5 This topic is particularly important now as surveys have shown that interest in GHEs among surgical trainees is very high,6,7 and regulatory bodies such as the ACGME have developed formal requirements for international rotations.8 Although these efforts are underway to formalize the curriculum of GHEs, there has been little discussion of the hidden curriculum encountered in host countries, and the hidden curriculum of GHEs themselves. We believe that considering the hidden curriculum in the host community and the underlying values of GHEs is as important as establishing formal curricular requirements. THE HIDDEN CURRICULUM IN THE HOST COMMUNITY When thinking about the differences in cultural values between home and host countries, most would initially think of differences in the food eaten or clothing worn. In the current age of pre-departure training, many trainees are also aware of the possibility of experiencing culture shock while on GHEs. However, the hidden curriculum also includes the cultural values within medical institutions. Trainees may not anticipate that the expectations of local supervisors (or even home supervisors while in a different context) may be very different from those at home. The unwritten rules about what a trainee “does” there may be different than what a trainee “does” at home. We recognize that these unwritten rules will be as varied as the differing environments in which trainees may find themselves. Issues may vary from acceptable questions during a history (the senior author learned quickly that it was frowned upon to ask about possible pregnancy in unmarried women in certain environments), to acceptable therapeutic maneuvers in the management of a patient (reducing an inguinal hernia in a child would only be done under sedation in certain environments, while it would be perfectly acceptable in awake, alert, screaming children in others), to acceptable behavior in and around the operating rooms (in some operating rooms, no masks are worn, while in others, everyone must wear one, whether scrubbed or not). It is often from the most implicit rules regarding conduct that ethical issues may arise. GHE literature, which is largely focused on undergraduate trainees, frequently alludes to the potentially unethical conduct of medical trainees while on GHEs.2,9 Yet, there is little discussion of the differences in expectations and values that often underlie these ethical challenges. Often, instead of offering practical advice on how to help trainees manage the sometimes conflicting expectations encountered on electives in a culturally sensitive manner, the literature stresses the importance of adhering to the formal values we teach at home and condemns the trainees who fail to do so. It is important to recognize pressures felt by trainees including their desire to “fit in” within the host system and to prove themselves just as they would at home. THE HIDDEN CURRICULUM OF GLOBAL HEALTH ELECTIVES The second and equally important hidden curriculum is the culture of GHEs themselves. The authors, as previous participants in a GHEs (albeit in different decades), both noticed that the experience made them more interesting to others. Colleagues wanted to hear exotic stories about medical and nonmedical adventures. On the medical side, it seemed the more extreme the presentation, the more complex the case, the more tragic the context, or the greater the suffering, the better. There was also an expectation for personal growth as a result of the GHE. Previous participants described it as an eye-opening or even life-changing experience. In contrast, few if any colleagues questioned whether we were a benefit or a burden to the host community. The tone and the types of conversations that take place around GHEs suggest our perceived value of these experiences. Our perception of the challenges surrounding the behavior of trainees while on GHEs is not unique as the medical literature has begun to explore similar concepts. Elit et al10 have described similar difficulties faced by medical students in navigating differences between cultures. The authors’ perception that the implicit value of GHEs is their potential for good stories and personal growth is also not unique; these benefits have been highlighted before in medical and nonmedical literature.2,10 In a study of Canadian youth participating in international nonmedical volunteering, personal growth was similarly found to be the most important motivation of youth to pursue these experiences.11 This lead the author to suggest that North-South international volunteering remains a form of neo-colonialism.11 Although perhaps a harsh criticism, one medical study has shown that voluntarism remains a common phenomenon and that it is sometimes excused on the grounds that it stimulates students to become involved in global health.12 The same authors also found that among those who have participated in GHEs, only a minority questioned whether their own involvement might constitute voluntourism,12 which suggests that the values underlying GHEs may still be unclear and hidden. CONCLUSIONS It has been suggested that the hidden curriculum can be influenced by increasing awareness, by encouraging self-reflection, and by role modeling.13 Although a structured approach for heightened awareness may be helpful, it has been questioned whether formalizing the “desirable” values and behaviors may only serve to increase the gap between what is taught and what actually takes place.1 In a similar manner, while establishing supervised self-reflection and role modeling may be formal requirements for GHEs, the quality of such processes and impact thereof may be variable. We suspect it will take more than formal requirements to change the conversation from one regarding a trainee's incredible experiences to one regarding the benefits and the pitfalls for the hosts and their community. Both conversations should be allowed to take place, but what our host communities think and feel, a topic rarely evaluated or expressed in the literature, will be a much more difficult conversation. We feel that better understanding of the hidden curriculum and contextualized teaching from experienced, thoughtful mentors will help address the hidden curriculum of GHEs and of the specific communities in which they take place. The latter implies that thoughtful, knowledgeable mentorship should be available, and that a process be implemented by which the mentor can sensitize and enlighten the mentee. Such a process may involve directed readings, didactic sessions, problem-based learning discussions, and formal descriptions of expectations before, during and after the GHE. Such a process may be a step toward assuring that host needs are recognized and addressed. A survey of Ugandan trainees’ perceptions of the impact of visiting partners suggests that some needs such as improving training are met but other needs may not be.14 For example, a significant number of Ugandan trainees had concerns about the ethics of clinical decisions made by visiting faculty.14 The first step in addressing the hidden curriculum of GHEs is the recognition of this entity. Although the concept of a hidden curriculum is not a new one, it has not previously been applied in the context of GHEs. Recognizing that there will be differences of opinion regarding the goals of electives—if there is desire for meaningful relationships where transparency, mutual understanding, and growth are crucial—addressing the hidden curriculum would seem essential. The time has come to recognize the hidden curriculum of GHEs, and of the host communities where they take place. Thoughtful stakeholders on both sides of such collaborative efforts have been addressing issues inherent in the hidden curriculum without formally defining it, or even recognizing it as a named entity. Institutions with extensive experience are re-assessing their global surgical initiatives, and trying to identify steps that will help to establish thoughtful, sustainable programs.15 Our hope is that by identifying and addressing the hidden curriculum in GHEs, we may take a step closer to the mutual understanding and equity that thoughtful partners try to achieve. As this is a previously unexplored area, and the hidden values of GHEs (and related activities such as medical missions and partnerships) may vary, we present mere suggestions rather than prescriptive recommendations in the hope to ignite thoughtful discussion among the surgical community.

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