The disavowed curriculum - Understanding students' reasoning in professionally challenging situations

CONTEXT: Understanding students' perceptions of and responses to lapses in professionalism is important to shaping students' professional development. OBJECTIVE: Utilize realistic, standardized professional dilemmas to obtain insight into students' reasoning and motivations in real time. DESIGN: Qualitative study using 5 videotaped scenarios (each depicting a student placed in a situation which requires action in response to a professional dilemma) and individual interviews, in which students were questioned about what they would do next and why. SETTING: University of Toronto. PARTICIPANTS: Eighteen fourth-year medical students; participation voluntary and anonymous. MAIN OUTCOME MEASURE: A model to explain students' reasoning in the face of professional dilemmas. RESULTS: Grounded theory analysis of interview transcripts revealed that students were motivated to consider specific actions by referencing a Principle (an abstract or idealized concept), an Affect (a feeling or emotion), or an Implication (a potential consequence of suggested actions). Principles were classified as avowed as ideals of our profession (e.g., honesty or disclosure), or unavowed (unacknowledged or undeclared, e.g., obedience or allegiance). Implications could also be avowed (e.g., concerning patients) or unavowed (e.g., concerning others); but students were predominantly motivated by considering disavowed implications: those pertaining to themselves (e.g., concern for grades, evaluations, or reputation), which are actively denied by the profession and discouraged as being inconsistent with altruism. CONCLUSIONS: This disavowed curriculum has implications for education, feedback, and evaluation. Instead of denying their existence, we should teach students how to negotiate and balance these unavowed and disavowed implications and principles, in order to help them develop their own professional stance.