How the Hidden Curriculum in Medical Training Increases the Cost of Health Care.

 A recent column by Pauline Chen in the New York Times exposing the culture of bullying that is still very much a part of medical education generated an outstanding number of comments from medical professionals affirming her facts (yes, indeed there is still a lot of bullying) as well as those insisting that it is only through instilling fear within a rigid hierarchy that patient’s lives can be saved.   Reading them leads me to consider how much harm this “hidden curriculum” actually does not just to doctors themselves and their individual patients, but to society as a whole as we struggle with the ever rising cost of health care.

Many of us in health law have written before about medical education and most articles include the phrase “hidden curriculum” to mean what medical students learn when they leave the classroom and go forth into their years of clinical training.   See Amy Campbell, “Teaching Law in Medical Schools: First, Reflect.” Journal of Law, Medicine & Ethics. 2012; 40(2);   It has also been blamed by ethicists who point out that whatever work is done in the classroom teaching empathy and professionalism is untaught on the wards. (I’ve written about this too-here ). See  Christopher Johnson  Here’s an interesting article from Academic Medicine showing how medical students’ attitudes about accepting gifts from pharmaceutical companies changes when they move from classroom to clinic. , Here’s another one talking about unfounded bias against family medicine physicians.

Here’s another, perhaps less discussed, bad thing that comes from the hidden curriculum: defensive medicine!  Uwe Reinhardt, Princeton health economist (which is like saying that Alfred Einstein was Princeton Physicist),  is often quoted as saying that defensive medicine raises the cost of health care—and he does say that.  But with more nuance that a short quote allows.  Here’s a fuller explanation in an interview in which he reviews some factors related to the cost of health care, and refers to defensive medicine as a “psychological” factor.  And psychological it is—along the lines of fear of alien abduction.  Medical malpractice law suits are rare events for most physicians, and, as David Hyman, Charles Silver, Bernard Black and Myungho Paik point out, even rarer in states like Texas which has essentially eliminated them through Tort Reform.  See more of their work here, here, and here.  Tom Baker, author of the Medical Malpractice Myth, has written extensively about how beliefs about malpractice are mostly unfounded (and I have tried to convey this message too). 

I’m in the preliminary stages of designing a study to look for the roots of this fear within the hidden curriculum.  It’s my been my experience as someone who teaches in both a medical and law school, that much of the fear doctors have of lawyers comes from the hidden curriculum.  We are often used as “the monster under the bed” to scare young doctors.  Some of the bullying Dr. Chen refers to takes the form of threats of malpractice.   But what if instilling disproportionate fear of malpractice not only poisons patient/doctor relationships but also raises the cost of health care for everyone? 

So what can we do to change the hidden curriculum and the harm it causes?  The first step is to recognize it.  One of my favorite themes among comments Dr. Chen’s article elicited  is that since doctors “are the only” professionals who hold the lives of others in their hands, those entering into medical training must accept abuse or not be doctors.

Well, interestingly there are some other professions that hold peoples’ lives in their hands and one of them is the airline industry.  Moreover, this is an industry which has transformed its training and its operating procedures in order to get rid of exactly the kind of hierarchy that now exists in medicine and which has been found to be a direct contributing factor in airline fatalities.  The story is well told by Malcolm Gladwell in a New Yorker essay and summarized in this WSJ blog post.    If the military and the airline industry can change the way it trains pilots, we, faced with similar issues of safety and cost, should be able to change the way we change doctors. 

JSB