Introduction

Perceived as a gateway into medicine, but not as the real start to medical school itself, orientation primes students for their subsequent four years of education and hints at their future lives as physicians. Orientation programs represent significant investments in faculty and staff time and institutional resources—at once bonding experiences for a new class, a regulatory necessity, and a forum for inculcating “practical” information. In its most aspirational moments, orientation reminds students and faculty alike why they have chosen medicine. What remains less clear—what, we argue, is hidden in plain sight—is that these days before medical school “actually begins” become a student’s first practice in discerning what information and values are “necessary” versus that which is “superfluous” or even “irrelevant.” This process of discernment is crucial to the practice of medicine, from diagnosing an illness to reading a pathology report to making a life-saving decision in the operating room. And yet it is also well documented that such patterns of discernment can also too easily allow “soft” information to be lost to “hard” facts, that critical judgment can bleed into bias, and that an individual capacity to understand a medical problem can interfere with the teamwork, structural as well as cultural competencies, empathy, and humility required of patient-centered care.

A great deal of scholarship has focused on these areas of inquiry within the context of medical education (Becker et al. 1961; Good 1994; Good and Good 1993; Holmes, Jenks, and Stonington 2011; Jenks 2011; Michalec and Hafferty 2013; Newton et al. 2008; Willen and Carpenter-Song 2013). In their special issue of Culture, Medicine, and Psychiatry devoted to contemporary biomedical training, Holmes, Jenks, and Stonington review models of seeing medical education as professional socialization, including dynamics of learning detachment and managing emotions (cf. Smith and Kleinman 1989), and the importance of “learning to prioritize ‘competence’ over ‘caring’” (Holmes, Jenks, and Stonington 2011: 108; Good 1995). Our article builds on this foundation. We explore one medical school’s orientation program, in relation to student and faculty experiences across the 4 years of medical school, as a way of analyzing how the “hidden curriculum” (Hafferty 1998; Hafferty and Franks 1994; Hafferty and O’Donnell 2015; Lempp and Seale 2004); Taylor and Wendland 2015) operates in the context of the more overt institutional goal of professional formation. The social science literature examining the hidden curriculum in medical education is robust. However, to our knowledge, no work has considered the hidden curriculum within the context of orientation, or explored how the explicit “tone” set during such events relates to implicit cultural assumptions that can reverberate through medical school.

At this “orienting” moment, students are diving deeply into, and responding to, new subjectivities. Orientation sets in motion these new subjectivities without overtly naming such an event as medical school. Rather, it can remain construed as the “touchy-feely,” the boring, and the obligatory stuff that comes before getting one’s hands dirty in the anatomy lab or learning how to take a patient history—moments which signify the “real” beginning of the medical path. We discuss how an event considered at once temporally prior to and discursively outside the “real” start to medical school actually marks the powerful entrée into new ways of being in the world, relating to knowledge, and treating oneself, each other, and the patients one will eventually serve. Like Holmes, Jenks, and Stonington suggest, we highlight moments when these implicit, value-laden orientations toward medicine are reflected back at later points in training, and we agree with them that students are not “passive subjects” (2011: 108). We argue that, while orientation does not, in itself, cement the ideals of the hidden curriculum, it primes students for the years ahead that will, by initiating such patterns of discernment. Even though students might not remember details from orientation, our data from interviews, participant observation, and focus groups with students across all 4 years shows that they come to notice, reinforce, and challenge the dynamics established during orientation in a longitudinal sense.

In this article, we focus on three areas of inquiry: definitions and practices of “professionalism”; dynamics of power, hierarchy and vulnerability; and issues related to social difference. We do so by first providing an ethnographic example drawn from orientation, followed by an “echo” of this example drawn from data that occurred outside of orientation. We close each section with analysis of the ways that implicit values from orientation endure throughout later years of medical education, and to what extent they are challenged. Each of these areas of inquiry—professionalism, power and hierarchy, and social difference—occupies a space between “humanism” and “hard science.” Professionalism is espoused throughout orientation as essential to being a good physician, and yet medical educators and students often define the concept by giving examples of what it means to be unprofessional. While medical educators indicate that hierarchy no longer defines learner-teacher relationships, that teamwork is the backbone of clinical practice, and that medicine has embraced a patient-centered model, orientation can reinforce social and professional boundaries and the elite quality of the profession, sometimes causing students to doubt whether they belong in medicine, wonder what they can and can’t say, and question their individual capacities. The use of Appreciative Inquiry (AI) as a method for engaging sticky issues of social difference attempts to nuance the static concepts of “diversity” or “cultural competency” as a means of understanding others. However, it can end up reifying difference, hindering deep listening, and closing the door on conversations about how structural inequality—understood as the intersections of race/ethnicity, class, gender, and histories of oppression—shapes student, faculty, and patient experiences of medicine.

We argue that despite an institution’s overt intentions to produce caring and community-engaged students who will become humanistic and collaboratively minded physicians, medical school orientation programs may direct individuals (or cohorts) toward very different values. Such “orientations” are also rites of passage that establish power, hierarchy, and authority and reproduce cultural norms, even as the overt goals of such events often hope to alter these historical and cultural realities. And yet, as we also show in the conclusion, moments of productive disruption—counter-narratives offered by students or faculty and embodied examples—can and do occur. These examples provide possibilities for recasting the culture of medical education, even within structures of institutional constraint. In the conclusion, we discuss the relevance of our findings for future curricular change; however, it should be noted that our work is an ethnographic study of medical education, not a programmatic assessment of orientation practices.

Research Methods and Setting

This article is based on ethnographic research conducted over an 18-month period (2012–2014) at a mid-sized, private northeastern US medical school. This project began as an exploration of how the hidden curriculum is contested, reinforced, or actively resisted when an institution is opened up to the possibility of curricular redesign (cf. Hafferty 1998). Here, “curricula” is understood as both the stated commitments of course hours and institutional planning and the less formal but no less influential or pervasive ideological frameworks that guide instruction and shape institutional culture. The research grew out of the first author’s initial involvement with an institutional working group tasked with creating an inventory of existing resources within the broad category of “ethics and the medical humanities,” which was to serve as the basis for developing a new curriculum that aspired to integrate more seamlessly issues as diverse as bioethics, physician burnout, and the social determinants of health into the core biomedical curriculum. To better understand the current status of such diverse (and divergent) issues as experienced by students and faculty, with a view toward how the hidden curriculum also shapes such issues, we embarked on a modest institutional ethnography, with support and encouragement from colleagues at the institution. The second and third authors—undergraduate students/recent graduates with training in qualitative research and academic interests in medicine as a career—were recruited and mentored by the first author throughout the data collection and analysis process.

As with much ethnographic research, this project was not hypothesis driven. Rather, it was inductive and followed an iterative process of inquiry, in which initial data collection leads to initial analysis, the revision of theories and assumptions, and the formulation of new questions. Data collection included semi-structured ethnographic interviews with students (25),Footnote 1 faculty (20),Footnote 2 and staff (3), as well as two focus groups with students. Initial interview questions focused on the individual’s path into medicine, perceptions about the institution, and reflections on professional formation. We also conducted more than 100 h of participant observation and informal conversation: during first-year orientation; in the first-year anatomy course and the annual memorial service for donated cadavers; at curriculum review town hall meetings, clinical rotations, and grand rounds; during the “White Coat Ceremony” at the start of the academic year; in core biomedical classrooms; and in courses dedicated overtly to inculcating ethics, professionalism, compassion, self-care, doctoring skills, and reflection. The first author conducted most interviews with faculty and staff, conducted some participant observation, ran the focus groups, and facilitated an Appreciative Inquiry session for entering first year medical students on the first day of orientation. The second and third authors conducted participant observation in the above settings, focus groups, and did most student interviews. Germane to this article, to understand how the curricular and educational objectives were presented to new medical students, the second author attended the full week of orientation and conducted participant observation in all sessions except those where her presence would have disrupted the bonding of the first-year medical students, which included some of the more interactive, informal, and less didactic moments. These data were transcribed and coded using both open and focused coding techniques as described by Emmerson, Fretz, and Shaw (2011), and following a grounded theory approach to qualitative data analysis (Charmaz 2006). Rather than following one cohort of students from first through fourth year, this research captured lived experience of students at different points throughout medical education, as well as faculty perspectives.Footnote 3 The analytical themes around which this article is structured emerged through the process of open and focused coding and were identifiable during orientation and at later moments. We do not argue for a linear cause-and-effect relationship between the events of orientation and situations described later. Rather, the veracity and consistency of these themes across different moments in students’ educations, and the ways these were also reflected by faculty, are a testament to the conditions under which social norms in medicine can surface during orientation and be perpetuated.

We do not discuss the institution’s efforts at curriculum redesign in this article. However, it is important to note that we conducted this research at a time of institutional uncertainty. The prospect of curriculum change was contested. Asking faculty and staff about experiences related to ethics, humanistic inquiry, and professionalism also provoked discussions about institutional insecurities, academic “silos,” and the balkanization of the teaching enterprise; debates about how or if one can teach empathy; and issues regarding institutional leadership. Discussions with students generated data on the difficulty of mastering new social scripts and navigating relationships with faculty and patients; mental health concerns, including managing emotions, fear of failure, disappointment, and doubts about professional choice; reactions to the highly variable quality of teaching as well as the impacts of novel pedagogies (themselves a ripple of curriculum change); and concerns about the relative lack of faculty diversity, including how this was shaping their education. These themes resonate with what we describe in this article, but are not the primary focus of this piece.

Finally, we provide some framing details about orientation itself. These 5 days in early August were a crash course in the major names, faces, groups, events, and expectations at this medical school. Approximately 80 first year students attended the event, which faculty and staff facilitated. While orientation largely occurred in an auditorium, small group discussions and embodied team-building exercises punctuated didactic sessions. Subsequent days of orientation introduced the mandatory course that teaches the basics of doctoring for the first two pre-clinical years, from physical exams and patient interviewing to professionalism and the honor code. Other sessions were an eclectic mix: discussion of service learning opportunities, medical school finances, preventing nosocomial infections, patient confidentiality, and developing a career in medicine, among other topics. At times, senior medical students were invited to participate. Social events throughout the week helped students to begin developing deeper relationships.

Feeling “Doctorish”: Defining and Teaching Professionalism

The successful modeling of professionalism depends on highly skilled facilitators who show (rather than tell) associated traits in classroom and clinical settings. This reality runs counter to a normative assumption that core biomedical knowledge is standardizable and should be able to be imparted by any institutionally qualified individual. Oftentimes, students learn patterns of discernment and qualities of professionalism via negative examples. Within the formal curriculum, sessions on professionalism were at once lauded and yet positioned as “supplementary.” Students were cognizant that efforts to model good professionalism, including empathy, remain separated from what was perceived as “core” medical education.

Orientation Moment: Wordles of Welcome

As new students settled into their auditorium seats on the first day of orientation, a projected Wordle described professionalism. “Respect” was the largest, followed by “honesty” and “collaboration.” Three slightly smaller words—“integrity,” “commitment,” and “humility”—nestled into the Wordle, giving it further shape. A faculty member asked students to define professionalism. Concepts bandied about included politeness, responsibility, dress code, trustworthiness, appropriate language, separating one’s own stress and bias, adherence to a professional code of ethics, timeliness, and being engaging.

The presenter encouraged students, affirming they had touched on “just about all the major aspects” of professionalism. At the outset of orientation, it seemed that “professionalism” became a simplified list of decontextualized qualities. The presenter drew on the American Board of Internal Medicine’s (ABIM) Physician Charter to define how physicians should behave. They should place patient welfare first, give the patient autonomy to choose amongst options presented, and work toward social justice by distributing resources fairly across the population. While aiming to justify the relevance and merit of “professionalism,” the faculty member legitimized this ethical framework for social formation and clinical practice by citing the “skyrocketing” number of peer-reviewed journal articles that had been written about “professionalism,” indicating that such nuanced and “soft” concepts are only justified with “hard” evidence.Footnote 4

In an effort to connect with his audience, this faculty member then showed a slide of the journal article “Does unprofessional behavior in medical school have subsequent consequences?” (Papadakis et al. 2004). He noted how unprofessional action had a statistically significant relationship to future punishment by state boards, and that men tend to be punished more frequently than women. The faculty presenter warned the room of new recruits that erosion of professionalism leads to abuse of power, greed, arrogance, and conflicts of interest. Efforts to define professionalism positively and discuss strategies for cultivating professional behavior led to defining what professionalism is not. This faculty presenter used examples of unprofessional behavior as a means of framing professionalism expectations of new students: he referenced the negative consequences of drug or alcohol use, conviction of crimes, and negligence. In a classic Foucaultian sense, this session became a way of using the concept of professionalism to discipline and regulate student behavior. Professionalism operated as a “technology of the self” (Foucault 1988; Jaye, Egan, and Parker 2006) even as it was at times pitched as a threat or severe warning.

As such, the value of professionalism seemed to rest in avoidance of negative consequences. Do this or else you will get sued or punished by a state board. Significantly, these framings of professionalism did not center on “burnout” or other mental health issues experienced by many medical students and physicians, reinforcing the stigma that “weakness” or vulnerability are anathema to being a professional doctor. Instead of justifying professionalism by pointing to the ways it can accomplish what it supposedly sets out to do—putting patients first and promoting social justice—it was presented as a tool for avoiding punishment or reprisal. If, according to the ABIM definition, professionalism is essentially all about the patient, we might ask: why do all the consequences relate to the physician herself, emphasizing consequences beyond self-care? These contradictions reflect the heart of the hidden curriculum, where students must discern and act out expectations based on conflicting discourse.

Next, an older student took the stage. To him, “professionalism” is vague by design. He emphasized that there is no “guidebook” on how to behave in most situations. Instead of speaking about negative examples, he emphasized intentionality: doing the wrong thing with good intentions is still better than doing the wrong thing with negative or unexamined intentions. This older student’s perspective on professionalism directly challenged scholarly definitions of professionalism espoused by the faculty member. Contrary to the faculty member’s warnings about what happens when students act unprofessionally, this older student acknowledged that people falter—and that this is expected. His approach to understanding what professionalism is and what it means in practice was process-oriented rather than outcomes-driven. This view is crucial, and yet was offered by an individual with significantly less authority than the faculty member. This focus on medical perfection on one hand, and being open about weakness on the other, can leave new students conflicted about what matters most and what professionalism means.

Echoes of Orientation: White Coat Ceremony

Several months after this orientation session, professionalism became the central focus of another medical school ritual for first-year students: The White Coat Ceremony. The white coat has come to symbolize the medical profession broadly (Becker et al. 1961; Blumhagen 1979; Wear 1998). For instance, during observation in a psychiatry clerkship where most providers wear plain clothes, one resident was wearing a white coat. After being poked fun at by other residents, he said he wore it to “feel more doctorish today.”

The White Coat Ceremony is the first opportunity for medical students to wear such a symbol—an important rite of passage into their burgeoning status as physicians (Huber 2003). Most US medical schools host a White Coat Ceremony for their first-year students in which they receive and begin wearing the coat. The ritual also has the effect of formally emphasizing a commitment to professionalism. At this medical school, the ceremony took place in a non-denominational chapel on campus. It opened with a performance from the medical school choir; followed by speeches from several faculty, student, and alumni; and concluded with students introducing themselves before receiving their coats. Family and friends of students attended the celebratory and reflective event.

In the opening speech, a faculty leader described the event as an opportunity to celebrate student achievement; to bear witness to their choice to enter the medical profession; and to emphasize altruistic duty: “At its heart, medicine is a humanist[ic] profession with the patient at its center.” He followed with a Biblical analogy of the Jordan River. Along this river, he explained, are the Sea of Galilee and the Dead Sea. The Dead Sea takes nutrients from the Jordan River but can support no life. The Sea of Galilee gives to the Jordan River, and life flourishes. He encouraged students to “be like the Sea of Galilee” while in medical school, providing examples of ways they could give back to the local community. His address ended with a wish that “our students would be characterized not by what they know but who they are.”

Next, the Medical School Dean took the stage and described the significance of the white coat. Historically, he explained, physicians have worn white coats to symbolize their purity and freedom from disease. This symbolism evokes trust in doctors by patients—a trust that he acknowledged as “a privilege and responsibility.” Receiving a white coat early in medical training literally envelops the first-year medical student in a symbolic field of professionalism, even as the definition of the term remains muddied. Like sartorial status symbols in other cultural contexts—the cloak worn by a Tlingit clan leader during a potlach, a monarch’s crown, the feather headdress of a Kayapo chief—the white coat signifies respect and authority, responsibility and expertise. It is also a “uniform” that comes to illustrate a form of elite belonging and an item invested with cultural expectations (Kaiser 1990; Wear 1998).

As an illustration of this dynamic, one faculty speaker at the ceremony remembered:

One day a patient didn’t want me, a student, touching them or being involved in their care. The overseeing doctor kindly told the patient that he only continued to practice so he could teach new students, and that if the patient refused care from the student he would have to find another physician. I was so inspired by this doctor’s passion for teaching and competency as a physician, that, for the first time, I became proud to wear my white coat.

This example transmits many important messages. It illustrates the ways that role modeling is central to the transmission of professionalism. It also confirms the power the physician can have over the patient, complicating the notion of patient-centered-care as it relates to professionalism. After all, the point of this story was not about patient empowerment or listening; rather, it was a kind, if firm, assertion of a doctor’s authority over a patient on behalf of a medical student, and, by extension, the medical profession. The underlying message relates to a fundamental ethical paradox of the profession of medicine: students must learn to practice on live patients (Gawande 2003).

While many students with whom we spoke felt that their white coats—shorter than those of residents or attending physicians—granted them a new form of legitimacy, most wore it as a mantle of authority that they were not yet certain how to bear. They noted that wearing a white coat can provoke new anxiety and self-questioning, particularly when a student feels uncertain about their knowledge or, more broadly, their choice to enter medical school. As both learners and care providers, students are particularly vulnerable (Chuang et al. 2010). They may struggle to balance conflicting priorities and responsibilities: patient care, clinical performance, and satisfactory grades, to name a few. This struggle manifests through a coping strategy that we came to call “scripting”—after Goffman’s (1959, 1967) seminal work on the presentation of the self and rituals of interpersonal interactions. We understand scripting as a process that relates both to dynamics of professionalism and to power, hierarchy, and vulnerability, as we describe in the next section.

One student aptly discussed this dynamic: “Many times it feels like you’re acting, you’re just trying out the script to see how it feels. And it’s also a time when we’re told it’s one of our last opportunities to make mistakes.” The student attempts to subvert the vulnerability of his position through a scripted response. In so doing, he can give the impression of competence. But there is a circular logic here. Messages reinforcing the idea that a physician must always be perceived as competent and confident encourage students to “fake it.” Other students implied that they were learning to follow scripts rather than think critically and deal with uncertainty or points of failure. High expectations, constant (self, peer, faculty) evaluation, and pressure to perform can compel students to fake medical competence, even if this contradicts widely-acknowledged aspects of medical professionalism: providing quality care and lifelong maintenance of clinical competence. Yet this pressure to perform, even if it’s false or forced, becomes a professional value in and of itself. Throughout the ceremony, “professionalism” was invoked as a synonym for humanism, compassion, and altruism. However, the ritual also suggested that one of the most important aspects of professionalism is “looking the part” even if one is not internally comfortable with the authority and responsibility this uniform connotes.

Discussion: Learning by Negative Example

In recent decades, medical educators have shown a renewed interest in seeing professionalism as a learnable, teachable competency (Wear and Castellani 2000), in part due to the recognition of negative aspects of the hidden curriculum and a documented decline of empathy of medical students during their training (Michalec and Hafferty 2013; Newton et al. 2008; West, Shanafelt, and Kolars 2011). This connection between “empathy” and “professionalism” is notable in its own right, but for now we focus on the fact that while professionalism is increasingly recognized as a worthwhile endeavor, defining and teaching this topic remains a challenge. Professionalism has become a catch-all concept for all humanistic aspects of medicine—except for where it dovetails with concerns over litigation or licensure. Moreover, it is usually positioned as supplementary or subordinate to clinical competencies (MacLeod 2011; Michalec and Hafferty 2013).

What does it mean that a faculty member said to new students, after a cursory group exercise, that they had touched on “almost all aspects of professionalism” with a few short words and phrases? This implies that professionalism can be understood as a rigid set of qualities: at best, a checklist against failure (cf. Gawande 2010) and at worst a check-the-box approach to being professional. This moment of defining professionalism with a new group of medical students was further complicated by the faculty member’s reliance not on models of process and mentorship but rather on the ABIM Framework—an official, disembodied source of power—as the ultimate definition. Instead of professionalism, students were impelled to conform to the rules of a professional body, which presents a list of responsibilities without offering guidance about how to accomplish them.

Pedagogical approaches to impart medical professionalism vary and are under constant revision, but many agree that role modeling is the most impactful strategy (Baernstein et al. 2009; Burford et al. 2014; Karnieli-Miller et al. 2011; Weissmann et al. 2006). However, successful role modeling relies on quality role models, begging the question of what faculty development entails. In interviews with faculty whom students viewed as exemplars, they often referenced being “self-taught” or recalled a deep interpersonal relationship with a mentor. Opportunities to develop critical self-awareness, to renew a sense of empathy, or to refresh one’s understanding of biomedical ethics depends on opportunities for professional and inter-professional development after medical school, and this is not a commonplace as one might hope (Weissmann et al. 2006). Moreover, negative role modeling and the consequent need to rectify discord between espoused curricular ideologies and observed “professional” reality poses a very real challenge for medical schools (Burford et al. 2014; Higashi et al. 2013; Karnieli-Miller et al. 2011; West and Shanafelt 2007).

When it comes to role-modeling, Passi et al. (2013) draw distinctions between clinical competence, excellence in clinical teaching skills, and humanistic personal qualities. This analysis highlights an implicit assumption that clinical excellence and a humanistic approach to medicine are distinct endeavors. We argue that this assumption is a key way in which the hidden curriculum plays out—and is allowed to continue. A disconnect between what students learn explicitly about these topics and what students observe implicitly, often through negative example, may cause a decline in empathy and humanism (West and Shanafelt 2007). But, it needn’t always. As one student mentioned in an interview, “I learned professionalism by modeling myself after people I think are good professionals. Oftentimes when we have these sessions entitled ‘professionalism.’ That’s when we recognize the people who didn’t model good professionalism. We kind of recognize it by contrast.”

“Get over It”: Power, Hierarchy, and Vulnerability

Despite faculty claims, stated during orientation and beyond, that students were their “peers,” hierarchical power dynamics infused medical education. Such power dynamics impact both faculty and students, and can be exacerbated by a perceived lack of safe spaces to express vulnerability, even when the official curriculum offered frameworks for such support. Students struggled with acknowledging vulnerability. They were less likely to seek out help or admit to challenges (such as those related to mental health and well-being) and were more likely to fake medical competence than to be perceived as ignorant or weak. These dynamics were couched within structural realities in which hierarchies of authoritative knowledge position “soft” competencies and curricular elements as supplementary to the “hard” sciences.

Orientation Moment: A Gathering of Peers?

On the first day of orientation, the Senior Advising Dean welcomed the new class. He shared his own background, introducing himself as the “grandfather” of this medical school. “At this school,” he said, “everybody knows your name, you know everyone, and alums around the world will open their arms to students.” He shared a story about a previous graduation address given by a famous alumnus who spoke about the Special Olympics. The Dean paraphrased: “One kid fell, and once all the other kids realized what happened, they all came back. The kids then crossed the finish line together.” The Dean continued, “That’s what we do at this medical school: pick each other up and go over the finish line together.”

Another faculty member echoed the Dean’s focus on camaraderie during a session to introduce the year 1 and 2 doctoring course. The presenter said that physicians at the school “see you as our peers, starting right now,” encouraging students to call on them for advice and help. The potential contradiction of this statement notwithstanding, we found that students did not feel like equals with faculty. At another orientation session, a second-year student commented on his leadership role at the school, which involved participating in a faculty-run committee. He expressed reticence to contribute, instead letting the “big shots” do the talking. Thinking of himself as “just a kid,” he thought the faculty members should be given a greater voice because “they have the experience and a lot more to say.” His comments reinforced a part of the hidden curriculum that espouses equality but acts out hierarchy.

A session on confidentiality and patient records during orientation illustrated the persistence of medical hierarchy, despite discourse to the contrary. The faculty presenter introduced Health Insurance Portability and Accountability Act (HIPAA) and the basic rules surrounding access and security of patient records. In an effort to capture the complexities of HIPAA, the faculty member sketched scenarios. Many of these sketches involved a senior physician asking a medical student to do something questionable. For instance, in one scenario, the attending was described as “too busy” and therefore “needs the medical student to pull all of the patient records for the day.” In another scenario, the attending is about to go on vacation and asks the student to send her, by email, a Word document containing confidential information. In a third scenario, the medical student is at a community practice unaffiliated with the teaching hospital. The community doctor asks the student to access university health records for a patient since she doesn’t have access, pressing the student and assuring him that “she thinks it’s ok for him to access it” when he resists. Each scenario represented a HIPAA violation.

While these sketches were pitched as light-hearted examples to acquaint students with the complexities of HIPAA, each one signified the power asymmetry between physicians and medical students and the inherent hierarchy in medicine, even though this was not overtly discussed. The locus of responsibility to follow HIPAA was placed in students’ laps, and the power differential itself allowed for the questionable scenarios to unfold. Throughout orientation, faculty presenters overtly tried to subvert the history of hierarchy through a narrative of egalitarianism, insisting that this institution was a special place, operating outside of traditional power asymmetries between faculty and students. And yet, at times hierarchy was so engrained that it was rendered invisible. New students grappled with the position of authority physicians historically and culturally hold, while faculty acknowledged the turn away from paternalism in medicine, from the “do as I say” model of medicine, as one faculty described, towards patient-centered care, a “trust-based, shared power relationship between doctor and patient.” This position directly challenged other narratives from orientation, but the dissonance itself in these crucial messages remained unaddressed.

Elements of orientation made some students question the extent to which they “belonged” in the room. Consider this example. On the first day of orientation, after recounting data on incoming class demographics, a staff member detailed individual class members’ achievements. At the end of this long list, he said that students might now be asking themselves whether they deserved to be here. He reassured students that they do, quoting C.S. Lewis’ Prince Caspian:

–“Welcome, Prince,” said Aslan. “Do you feel yourself sufficient to take up the Kingship of Narnia?”

–“I - I don’t think I do, Sir,” said Caspian. “I am only a kid.”

–“Good,” said Aslan. “If you had felt yourself sufficient, it would have been proof that you were not.”

His point was that if you’re not at least a little humbled by your choice to enter medicine, then it would be cause for worry. Overt attention was given to the fact that students made it to the top of many academic and extracurricular hierarchies to be admitted, and that being among their accomplished peers might make them feel insignificant.

Informal discussions with students after this event and later interviews revealed ambivalence about this strategy. Some thought that attention would have been better placed on the doubt surrounding whether one was ready to be a doctor and entrusted with lives—rather than whether one was good enough to be amongst these peers. The incitement of fear and awe in regard to others’ achievements reinforced social divides amongst students, challenging the idea that this exercise created a sense of unity and belonging. Comments from a faculty member at a later orientation session emphasized students’ status as both emerging physicians and students at this school. He mentioned the types of scores that students from this institution receive on the board exams, stating that they are higher than the national average. Then, half-jokingly, he said, “So, don’t mess up our good scores.” Here, too, the idea that medicine is about cooperation faded against an assertion that medicine was about individual success which, in the aggregate, reflected positively on the institution, reaffirming its position in a national hierarchy of medical schools.

Near the end of orientation, first year students heard from second, third, and fourth year peers at a panel titled “What I Wish I Knew.” Here, a hierarchy of knowledge and curricular priorities emerged. One older medical student on the panel said, “[The year 1-2 required clinical skills course] is really why you’re here: to develop your clinical reasoning mind. Don’t push it aside. It will be easy to push aside since you’re getting grades every couple [of] weeks in your other classes.” Another student panelist stated he was afraid of losing what he came here for: the desire to serve. In explaining how he addressed this issue, he drew on extracurricular experiences. A senior faculty member jumped in to say that what is important for patient care doesn’t always overlap with what’s important for the test. “You can help us by saying whether you think the course objectives align with what you need to know or should know,” he went on.

Without explicitly stating it, each of these speakers highlighted a division in the curriculum and the tendency to value some parts over others. They suggested that the institution is responsible for the “hard stuff” while students must rely on internal discipline, motivation, and extracurricular activities for the rest. The first student to speak on this panel recognized that classes like the year 1-2 doctoring course don’t receive the formal recognition that “hard science” classes do, warning students of the risk posed by this attitude. The second student expressed vulnerability by owning his fear of losing sight of his motivation to study medicine throughout the course of medical school. This comment also revealed mixed messages about the relationship between the formal curriculum and the notion that “optional” service experiences are where meaning and purpose (not to mention good models of professionalism) should be found. Other aspects of our research regularly reinforced these findings, indicating that such messages presented in orientation initiate patterns of discernment that can continue to manifest throughout medical school and beyond.

Echoes of Orientation: Spaces of Silence

Dynamics of power, hierarchy, and vulnerability surfaced through discussions about clinical experiences with older medical students, as revealed through interviews and participant observation during didactic and clinical settings. Consider this example from an interview with a fourth-year student, who witnessed the following during an emergency operation:

I really saw how that surgeon was so hyper-focused on just the anatomy of what was going on in front of him that he didn’t effectively use his team members… And these were things like making sure the anesthesiologist had blood in the room, or making sure that the appropriate tools were set up… so that … the scrub nurse knew what the plan was so that she could have… the appropriate instruments ready… since time was really intense… That would’ve been a way where [if] everyone was involved and everyone might have given ideas, that could’ve actually helped the situation and led to a better outcome.

The student understood what should have happened, but the reality was far from ideal. The student went on:

It felt really frustrating that, in my opinion, what that surgeon needed was not better technical skills. What he needed was better leadership skills. And it was really frustrating to see the team run off the rails… Even if I was, like, “I think you’re having a team problem, sir,” he would have no idea what I meant, and he would be, like, “Why are you saying this to me now? … We have to control the bleeding! We don’t care about the team.”

High-stress medical situations can cause a breakdown at the moment when good communication, in spite of conventional hierarchy, may be crucial. The medical student was able to “see” this reality more clearly than the attending physician. But as a medical student, this person did not feel comfortable speaking up, or have any confidence that, if she had, she would have been heard.

Other observations during clerkships offered insight into the realities students experienced with respect to power, hierarchy, and vulnerability. In the surgery clerkship, for example, conversations were generally between the senior residents and attending physicians. When medical students did ask questions, they always referred to the resident or attending as “Doctor X,” while the medical students were referred to by first name—if attending physicians even knew their names. Some physicians occasionally asked questions of medical students, and did not dwell on wrong answers. Others made the hierarchies in the room very clear.

Weekly Morbidity and Mortality (M&M) conferences were another site for the reinforcement of hierarchy in a space that is, in other respects, supposed to be a “safe” place for physicians at different stages of training and practice to learn from difficult situations. In one participant observation session, a resident and intern expressed that M&M is their favorite of the weekly conferences because attending physicians “get picked on” and “are torn to shreds.” The intern and resident reveled in the role reversal—seeing the attending physicians get their comeuppance. This manifestation of the hidden curriculum in action is a clear departure from the idea of creating a supportive, let alone an egalitarian, culture of medicine.

Student experiences as recounted in our interviews make it clear that medical hierarchy persists, complicating efforts to learn professionalism and practice empathy. As one student explained:

I have to think of who could possibly [model empathy] and then who would be the best person… it’s your resident and your attending. [But] there’s a dynamic with those individuals that makes it difficult to have an emotional experience. The clerkship director, clerkship coordinator—there is a power dynamic there. A fellowship with other students is very helpful and is something that I think almost all of the students rely on. But in some cases, it’s kind of the blind leading the blind.

These hierarchical relationships tended to be characterized by intimidation, fear, and the sense that you must not only adapt to new power dynamics but also learn to curtail emotional response (Bould et al. 2015; Smith and Kleinman 1989).

Hierarchies simultaneously increase students’ and clinicians’ feeling of vulnerability while denying them places to express it comfortably. One astute faculty member spoke to difficulties that students experience in emotionally charged situations: “[Students] feel so vulnerable they don’t want to come forward … They develop a sense of ‘get over it.’ You know, it’s happening to all of us, what do you think, you’re special?” All too often, experienced professionals fail to express emotion after a rough situation with a patient, implying to students that emotional expression isn’t important, or that a lack of emotional response is normal. This, too, recapitulates hierarchy, as well as what is and is not “acceptable” behavior. As one student noted about experiencing his first patient death:

I was doing chest compressions on a guy who’d just had a heart attack and then we stopped, and our team walked away, and the general consensus was that it had been a “successful” experience. We had done everything we could and it just didn’t work. First of all, it was my first time doing that, and it didn’t feel terribly successful. And I was surrounded by people who had done that dozens of times, probably. I was the only medical student, and so it was just pack up and move on.

The student felt alone in his expression of emotion in a situation that seemed old hat to everyone else. Ostensibly, this example illustrates “teamwork” in medicine, unlike the surgery example above, but this is teamwork only in the technoscientific sense, not in a way that creates spaces for vulnerability and reflection.

The pervasive framework of emotional distancing within the culture of medicine is reflected in the curriculum’s hierarchy of knowledge: divisions between curricular or extracurricular moments that reinforce the “art of medicine” and the “core” biomedical curriculum. During our interviews, many faculty members who work to oppose the subordinate position of discourses of caring, spaces of vulnerability, and the existential questions that exist beyond highly competent technoscience shared their frustrations in relation to the institutional and cultural norms they face. One noted, “We’re constantly struggling to assert—I know it seems so obvious—that the clinical skills they’re learning are much more important than their ability to … remember things they can always look up …It’s crazy!”

Echoing the faculty member’s frustration, students grapple with balancing the “hard” and “soft” aspects of medicine, particularly in light of their relative positions in the hierarchy. As a first-year student put it:

An important part about medical school is how it affects us and how it affects other people and how everybody feels about that. Part of me sort of is a hard-ass and thinks, “Oh, that’s pansy stuff,” like, “You should’ve spent all your time learning about physiology and learning about all these things so that you can make the best kind of diagnosis so you can have the best kinds of outcomes in morbidity, mortality…” I think I’m sort of torn between those two extremes.

The binaries expressed by this student reinforce the idea that the curriculum houses both overt and hidden hierarchies of knowledge and value, and that technical proficiency and self-reflection are somehow disconnected.

It is important to note that difficulties expressing vulnerability can be bidirectional: students may feel loath to express vulnerability for fear of a superior’s impression of them; clinicians may not want to show weakness to someone who needs to trust their direction. Aase, Nordrehaug, and Malterud (2008) observe that individuals within the profession are expected to handle and manage vulnerability on their own because both the culture of medicine and the systems in which it lives offer few formal spaces to unpack emotionally trying situations. This leads to the notion that the suffering you witness is a burden to bear, but not something you can “let get to you” (Aase, Nordrehaug, and Malterud 2008). One faculty member explained, “If you thought about every aspect of what they and their family are going through, you couldn’t function. And so, I kind of have … two sides to my brain …It’s a hard dichotomy to learn without becoming a robot …There’s probably not enough deliberate teaching about that … The way I learned it was by watching.” This observation illustrates Lief and Fox’s (1963) enduring insight that medicine trains people in “detached concern.” It is also a contributing factor to what many have called medicine’s “burnout epidemic” (cf. Dyrbye et al. 2008; Shanafelt et al. 2009, 2012; West, Shanafelt, and Kolars 2011).

Discussion: Knowing One’s Place

In considering examples from orientation and post-orientation data, we see issues of power, hierarchy, and vulnerability playing out in multiple ways. In the case of orientation, the discrepancy between the Senior Advising Dean’s characterization of the medical school’s culture and students’ experience indicates a generalized tension in medicine, which struggles to integrate values of supportive collaboration within a domain that values authoritative knowledge and singular expertise (Jaye, Egan, and Parker 2006). While teamwork is increasingly considered an important aspect of clinical practice (Baldwin Jr. 2007; Epstein and Hundert 2002; Karnieli-Miller et al. 2011), hierarchies abound: between students and residents, residents and attending physicians, inter-professionally, and between care providers, patients, and families. As the HIPAA scenario example from the orientation section illustrates, the hidden curriculum reinforces medical hierarchy to such a degree that one could argue it is an unintended consequence of professionalism itself. In one study, students identified it as such, pointing to the superordinate-subordinate relationship, keeping rank, and not overstepping as important to being professional (Monrouxe, Rees, and Wendy 2011).

Here, we identify a core tension that can exist between forms of medical hierarchy and efforts to subvert that hierarchy through narratives of egalitarianism, and the use of words like “teamwork” and “peer.” While certain aspects of hierarchy are arguably appropriate in medicine, this becomes problematic when hierarchy turns toward an ethos of humiliation and fear that can be medical authority’s doppelgänger. This raises productive questions about how this and other medical schools might foster alternative ethical bearings that emerge from models of caregiving and mentorship instead of intimidation. We certainly bore witness to examples of such alternative models of respectful hierarchy and the creation of “safe spaces” in which to express vulnerability throughout the course of our research, and we highlight several of these in the Conclusion. Although beyond the scope of this paper, a careful analysis of such spaces and encounters could not only contribute to highlighting the practical value of such models but also to ongoing efforts in medical anthropology to theorize morality and the “ethical turn” (c.f. Kleinman 2007; Mattingly 2014; Fassin 2014) as well as anthropologies of care and caregiving (c.f. Stevenson 2014; Buch 2015).Footnote 5

With respect to the position of social hierarchy that a career in medicine proffers, as others have written (Jaye, Egan, and Parker 2006), our data demonstrates how faculty sought to affirm students’ eventual place within the medical profession, to send the message that they “belong,” during and after orientation. And yet doing so asserts the elite status of physicians not only within the healthcare system but also in society at large. Faculty leveraged the school’s elite status to promote both a sense of belonging and to reinforce power. The emphasis on student scores on the United States Medical Licensing Examination introduced yet another division while simultaneously seeding potential tensions between the incoming class and those who have come before them, rather than inspiring camaraderie.

The “hidden in plain sight” division in the curriculum between “hard” and “soft” topics was introduced at orientation and reinforced at other moments, illustrating a hierarchy of authoritative knowledge within medical education that limits spaces of vulnerability and reinforces power dynamics at multiple levels, including within the curriculum itself. While institutions consider imparting evidence-based medical knowledge essential, they often view teaching humanism as an “add on.” We agree with MacLeod, who observes, “Discourses of competence tend to be privileged while those discourses of caring are often marginalized” (2011:375). As Byron Good has described in his work at Harvard Medical School (1994), medical students are often considered to have benevolent motivations for entering the profession. In fact, at one orientation session, the following question was posed: “What is the primary reason you have entered medicine?” The vast majority—more than 85% of the incoming class—answered either “to help others” (44) or “to serve the underserved” (25). Yet a hierarchy of curricular value assumes that the institution’s primary responsibility is to develop core biomedical competence, while the humanistic aspects of medicine are either framed as an “innate” quality of individual students or as the student’s responsibility to develop. This development occurs partly through informal mentorship, and with the recognition that faculty members don’t necessarily “practice what they preach” (Michalec and Hafferty 2013).

“Have You Had Any Magical Diversity Experiences?”: Listening Across Difference, Seeing Structures

Medicine’s strong need to categorize and universalize human experiences of illness can interfere with teaching the equally important skills of living with uncertainty and complexity, and listening. This dynamic becomes particularly evident when dealing with issues of social difference in medicine. Formal pedagogical efforts geared toward teaching students how to approach “diversity” or be “culturally competent” can limit their capacity to develop deep listening skills, or to render visible the structural vulnerabilities that shape health outcomes. Faculty and students alike stressed confusion and frustration over a “check the box” approach to social difference, and disparate views over how to best approach these aspects of medical education.

Orientation Moment: Click If You Identify

On the first day of orientation, faculty and staff responsible for fostering “diversity and inclusion” held a session entitled “Building Excellence and Community through Diversity and Cultural Competency.” The session intended to introduce students to the concept of “Appreciative Inquiry” (AI), which aims to find the values and strengths of every organization or community, to identify “peak positive experiences” as a method for facilitating change, and to use stories as an essential form of gathering information (Cooperrider and Whitney 2005). The session also included a service learning reflection, and a moment when faculty encouraged students to write a letter to their “future selves.” After presenting a list of extracurricular activities that faculty and staff felt related to broad topics of “diversity and inclusion,” the faculty member stated that her office “deals with matters of the heart.”

Next, students were given anonymous clickers and were asked to select from multiple-choice options to classify themselves. These classifiers ranged from issues of social class and medical lineage—were their parents also doctors?—to sexual orientation, race and ethnicity (with a notable absence of options for self-identifying as belonging to more than one group), to more innocuous prompts such as favorite type of music. We noted many dynamics within this session, including the possibility that some questions—What race/ethnicity do you identify with? Is anyone in your family a doctor?—could have the effect of alienating people or heightening difference rather than creating connections.

The faculty member then described AI as a way to engage with positive aspects of an interaction through listening, self-reflection, and dialogue. There was no clear articulation of how AI related to “diversity” or “inclusion” and no discussion of how “diversity” itself could be shaped by structural inequalities. The faculty member urged students that if it felt awkward to engage in this kind of conversation with peers, they should think about how they would have similar conversations with patients. The implication was that learning how to approach diversity (very broadly defined as synonymous with social difference) in medical school through AI would help students interact with a range of patient populations. The student body then split up into small groups and was led through an AI “practice exercise” by faculty facilitators. Prompts for this session included: “What are your hopes and fears for entering medicine?”; “How did you know someone cared the first time you met them?”; and “Have you had any ‘magical’ experiences with diversity?”

After small group meetings, the entire class reconvened and summarized their discussions. In relation to “care,” most groups mentioned the importance of physical connections like touch, eye contact, and body language. Groups agreed on other qualities of someone who cares, including demonstrations of compassion, asking questions, listening and reflecting, and showing vulnerability. With regard to diversity, people most commonly described the importance of starting conversations and listening, as well as placing experience over expectation (not “judging a book by its cover”). This portion of the AI session prompted some students to talk about ways of understanding each other, or a future patient, without reducing them to a list of check-the-box characteristics, despite the rather essentialized concept of a “magical” diversity moment.

In this exercise, discussions of diversity were linked to emotion (“matters of the heart” or “care”) and framed around individual actions and behaviors, without space to consider the political-economic contexts that shape social difference, including how it informs the practice of medicine or dynamics shaping health and illness. The focus on individuals, to the exclusion of structural inequalities that impact health, revealed the tendency to understand people (patients, fellow students, physicians) as self-contained units, rather than to understand them via health-shaping life contexts. Such practices of discernment were reinforced in conversations with older students and faculty. A mention of flaking paint in a community as a risk of child lead poisoning was the sole acknowledgement of how socioeconomic status affects patients’ health. (Notably, references to socioeconomic status were strongest in a later student-led panel on community service, in which they discussed extracurricular projects focused on underserved populations.)

Echoes of Orientation: Between Listening and Assuming

Given its geographic location, this medical school presents unique opportunities and faces distinct challenges with respect to educating students around issues of social difference in medicine. On the whole, the student body is far more diverse in terms of race/ethnicity and country of origin than the faculty. Although such a characterization may actually reinforce the idea that “diversity” is just about observable differences of ethnicity or culture, this was a reality that both students and faculty grappled with. While the patient populations at the associated teaching hospital are fairly homogenous in ethnic terms, the region is divided in powerful ways along class lines in ways that are often not visible to students, at least initially, and that add a layer of complexity to how “diversity” manifests between students, faculty clinicians, and the patients they serve.

On the first day of the Community and Family Medicine clerkship—one of several opportunities for students to do rotations in other parts of the country—one student said she was most looking forward to working in California with “people more like me.” She was Latina and lamented what she felt was a lack of diversity in her educational experience. This asymmetry plays out in a variety of ways. Some students said they felt they’d missed out on an important part of their medical education. What this “missing out” entailed varied: interacting with patients across social difference; being mentored by people who shared their background or experience; or not being stereotyped or misunderstood by faculty or patients themselves. Notably, this student’s observations arose in the context of a Balint group being led by the clerkship director. Balint groups grew out of the Balint Society, founded in the UK in 1969, with an explicit focus on the importance of emotion and personal understanding within medicine, between doctors and in the doctor-patient relationship.Footnote 6 In an interview, another faculty member acknowledged some of these issues, while also, perhaps unconsciously, embracing the notion that it was only students from “diverse backgrounds” who had “culture.” He said, “I don’t think we understand a lot of the cultural beliefs about the students. And students learn to maybe not say anything about that… I don’t think we’ve gotten to the point where we can really share those kinds of things… We have a long way to go as far as cultural competency goes.”

Faculty and students alike recognized that confronting issues of social difference requires deep, careful listening that often takes time and challenges assumptions. One student expressed the importance of listening, and how this tactic enables greater understanding, regardless of differences between provider and patient: “When a patient … talk[s] to you about what they’re going through or their suffering, their pain, [it is important] to not judge them by how your perception is toward some things, and be able to really think in terms of their experience, or in their perspective.” In this instance, questions about cultural competency and diversity prompted this student to think about listening, rather than static categories.

Some faculty perspectives mirrored those of students, while other comments revealed dynamics worth unpacking. One faculty member said:

Cultural competency is something that we can teach or be more aware of… But the reason I think it is … somewhat artificial is that if we step back about being more open, then the cultural competency thing will come as part of it. I may know nothing about what Haitians know about medicine, but if I am more open to the patient, without fear of reprisal or judgment… I can do the same about sexual practices…If I am open, I don’t have to know everything to be competent… That becomes competency even though I didn’t know anything about it.

This quote is at once illustrative of faculty goodwill and the desire to address social difference, and represents various levels of “othering” and misunderstanding. That “cultural competence” needs to be included as a professional value and taught in medical school is almost universally accepted. In part, cultural competency has been lauded as a strategy to address growing health disparities. But such a strategy is predicated on assumptions that culture and disadvantage are related in significant and predictable ways, that malleable dimensions of clinical encounters contribute to disparities, that culture is a problem to be fixed or even pathological, and that culture is distinct from biology (Willen and Carpenter-Song 2013). In contrast to the idea of “cultural humility,” which tends to acknowledge power and uncertainty in medicine and invite self-reflection, “cultural competency” can also lean toward “trait-based” framings of difference that can quickly devolve into stereotyping (Carpenter-Song 2007). This particular quote not only presumes that “Haitians” all know the same thing about medicine, but also that “competency” will just come—as if second-nature—through being open, and that it doesn’t require knowledge, practice, or expertise.

Increasingly, it is understood that what has become known as “cultural competency” in medical education may work against its stated aims of increasing tolerance and understanding through a trait-based approach that can perpetuate stereotypes and bias, reinforcing problematic patterns of discernment (Jenks 2011). As has been observed at other medical schools (Brooks 2015; Willen 2010), students we interviewed recognized this dynamic. One student referenced how “people in my class were really offended by some of the language used [by faculty],” including “a couple sort of racist comments made by people who were presenting, without even realizing it.” Most of these instances had to do with describing race as a fixed biological trait rather than a socially constructed reality, or the assumption of white, primarily male, and cis-gendered bodies as the “norm” in the context of didactic learning. Others had to do with the ways in which instances of practicing medicine across social difference were described. In one instance, a nurse was describing “her first experience on her own, bathing a large black man as this ‘horror experience’… And then another person made a comment, ‘You wouldn’t realize people are poor because they look like us,’ meaning like, they’re all white, which…clearly my class is very diverse. So, I know a couple people who were really upset in those classes.”

While students and faculty alike critiqued the lack of overtly distinguishable—one might say phenotypic—diversity both among the faculty and, in different ways, within local patient populations, they also acknowledged other forms of social difference. Some students were forced to confront and expand how they defined “diversity” in light of their experiences at local outpatient clinics and hospitals. The region is quite socioeconomically varied and also rural. One student shared what was, to her, a revelation: “I guess the rural thing has come up, and that’s kinda new to me…It’s interesting for me to hear, ‘Oh, you hurt your back. Does that mean that you’re gonna have a hard time chopping enough wood to keep your house heated this winter?’ I would’ve never thought of that question.” Part of productively addressing social difference in medicine entails recognizing how patients’ realities affect their health, including the capacity to “see” structural inequality and identify socioeconomic determinants of mortality and morbidity—encapsulated in the movement toward teaching “structural competence” (Metzl and Hansen 2014), which we describe below.

Many students felt that few spaces within the formal curriculum—outside of the year 1 and 2 doctoring courseFootnote 7—helped them to practice unpacking such situations or opening up difficult discussions that productively illuminate individual and structural norms, biases, etc. Students really noticed when they perceived faculty preceptors to handle such situations with care. One third-year student described:

I had this pediatrician who was a great preceptor, and she was really good at modeling cultural competency…What I mean by cultural competency is really trying to understand where somebody is coming from, and how it affects their care…their behavior and their actions…For example, we had this kid who she put on antipsychotics at a young age. He was 4 or 5, and she really agonized about the decision. But this kid lived in a poor family with four other kids, and the mom was really, really stretched, and really needed him to be more under control. She said, “For any other kid, I don’t think I would’ve done this. [But the mom] doesn’t have the resources to do this behavior modification that we would love to be able to do with him, and I’m going to try and find him those resources. But for now, as a stop-gap, I feel like I need to prescribe this.” She figured that out because she really worked with this family.

Understanding the lived experiences of patient populations also requires paying attention to language—how to listen as well as how to speak and act to maximize trust and inspire understanding, including in the face of difference. The above example is complex. It shows a student’s interpretation of a physician’s efforts to be attuned to what matters most to a patient and family—being an astute listener and communicating empathy—and using clinical power to provide some relief. Yet it also reveals a differential in individual care based on socioeconomic status. This, in turn, points to a structural inequality that complicates a “reading” of this example as illustrating empathy: namely, lower socioeconomic status children are treated more often with antipsychotic medications than their middle-class counterparts, despite the fact that many of the antipsychotics prescribed are not necessarily tested and approved for use in children (Carpenter-Song 2009).

Discussion: From Appreciation to Understanding

Significant scholarship over the past several decades has focused on the ways biomedicine is a cultural system and clinical medicine is a cultural practice (cf. Lock and Nguyen 2010; Rhodes 1996). So, too, with the need to take seriously not just cultural difference but also structural vulnerability in medicine (Bourgois et al. 2017; Farmer 2004; Wear 2003). Yet the sensibility that medicine is a “culture of no culture” (Taylor 2003a) remained present in our data. Added to this was the sense, among some medical students and faculty members, that only patients are “diverse,” or that cultural difference remains, most of all, a challenge to overcome in medicine (Taylor 2003b). At times, disparate dynamics were glossed with the terms “diversity” or “cultural competency.” Both students and faculty expressed uncertainty not only about what these concepts meant, but about how to approach the dynamics underlying them effectively.

For example, while the basic goals of the orientation AI session were laudable, framing diversity around one-dimensional categories or the use of the word “magical” exoticized difference. It failed to acknowledge the variability every person brings to interpersonal encounters or to clearly define what was counting as “diverse.” Moreover, a focus on “appreciation” runs the risk of narrowing reflection. What about experiences with “diversity” that were uncomfortable and unsettling? Additionally, “diversity” was positioned as a foil: a community-building tool and a metaphor for thinking about patient communication. AI ostensibly rejects a static “culture concept,” yet this session relied on the equally static and heavily scripted concept of “diversity” as a pedagogical prop. These observations beg the question: Why was the concept of diversity used as a proxy for talking about the effective communication that can illuminate and perhaps bridge social difference?

Open conversations about social difference can be welcomed in many spheres, and yet such discussions can also be lightning rods. The pairing of AI with discussions of diversity and cultural competency at orientation assumed that AI could get at the heart of diversity. This conflicts with the fact that faculty asked students to reveal the “diversity” in their backgrounds via positivist variables in the clicker exercise. The process of choosing predefined, restrictive descriptors limited students from expressing more complex identities and promoting deeper discussion, including conversations about social class. This exercise initiated a pattern of discernment we saw reflected in older students and faculty by priming new students for a trait-based approach toward issues of social difference, instead of creating a foundation from which to unpack assumptions and deepen abilities to listen. As Carpenter-Song (2011) has written, an alternative to this approach might emphasize what Judith Butler (2005) describes as “recognition”—interrogating the question ‘Who are you?’—as a model for thinking about diversity, particularly in the context of clinical relationships.

In our interviews, students of color and queer students expressed explicit sensitivities to the pervasive sense that white heterosexual realities were the “norm”—the unmarked understanding of who “we” or “us” signaled in didactic and clinical settings. The assumptions about whiteness as the norm, either for patient populations or physicians, can be challenged at many levels, not least of which is the fact that the physician population in the US has become much more ethnically diverse over the past few decades. It is true, however, that entry into the profession of medicine still favors the educated and relatively wealthy and that social class remained an under-discussed issue. As one first year student observed:

Medicine’s a really privileged profession. If you look at who goes into this, and … I’m not an exception, but it’s rich white people. And for a long time, it was rich white men. And so, the culture, if you look at our professors, they are [mostly] white men who I would guess didn’t grow up in a trailer park. And I mean I have a friend who…she’s a resident now…and we were talking about disparities of care, and she’s like, “I don’t know that every patient does need to have access to health care.” And I was like, “What?”

The sense that socioeconomic security defines a physician’s position, or that patients without means don’t deserve access to care, elucidates a broader sociocultural narrative in America about healthcare as an “entitlement” versus healthcare as a “human right”—a narrative that has arguably reached an apex in the present political moment. Engaging in Appreciative Inquiry about “magical” diversity moments is neither necessary nor sufficient to prepare a new generation of physicians for these challenges.

Conclusion

In this article, we have used the framework of one medical school’s orientation program and its reverberations through other moments in a four-year program, to explore aspects of medicine’s “hidden curriculum.” Despite vast literature on medical education, there has been little analysis of the relationship between these “orienting” moments and the social reproduction of core values within the culture of medicine. Our analysis finds that orientation primes students for many of the “competencies” of the hidden curriculum and initiates patterns of discernment that run the risk of entrenchment and reinforcement throughout their education: that the value of professionalism lies in avoiding negative consequences; that professionalism and other humanistic endeavors occupy a supplementary (or marginalized) position within the official curriculum; that hierarchy is alive and well in medicine, despite language to the contrary; and that addressing social difference in medical education can remain muddled, reinforcing stereotypes or relying on static definitions of culture or diversity despite stated aims to the contrary. While our ethnographic research was not undertaken as a form of program evaluation, our findings have implications for curricular reform. To use a medical analogy, just as preventive care can stave off the onset of disease and promote health, directly engaging the attitudes and behaviors that constitute the hidden curriculum during orientation could encourage positive shifts in the cultures of medical education and clinical practice.

We note, as a limitation, that the ethnographic research presented here reflects research conducted at a single institution in the United States. This research, including the focus on orientation, may not represent the culture of other institutions in the US or globally. We acknowledge that further research which endeavors to compare the orientation programs of several schools could be fruitful, perhaps also in the context of broader institutional ethnographies of medical education and the social formation of physicians, including a view toward “best practices” for orientation programs. Despite this limitation, we assert that the lessons gleaned from this study likely resonate with other US institutions and may provide a basis for compelling cross-cultural analyses of medical education in other national contexts.

It has now been several years since the data collection phase of this research. Throughout this period, the first author has reported back on this research to colleagues at the medical school, welcomed their feedback on initial data analysis, and engaged in discussions about how our findings could inform ongoing efforts at curricular reform. Although the institution decided not to pursue a full-scale curriculum redesign, it has embraced alterations to the curriculum that aim to address more comprehensively both externally mandated (LCME) competency metrics and institutional commitments, however uneven, to institutional culture change. It is quite possible that the events we describe herein are different now than they were in 2012–2014. However, we argue that shining a light on orientation and its echoes remains valuable.

Although we have focused this article on the ways that difficult cultural dynamics established during orientation are reflected across longitudinal medical education experiences by students and faculty, we choose to end with three quite different examples from this same institution—efforts that resist, confront, or otherwise challenge pervasive norms, but do so within the framework of dedication to and belief in the educational mission of this institution. Each example represents a commitment to productive disruption of the hidden curriculum. Aspects of each example could also represent all three areas on which we have focused in this article: professionalism, hierarchy, and social difference. For illustrative purposes, we tie each positive example to one of these core areas of inquiry.

With respect to professionalism, one of the most successful examples we witnessed was the use of Balint group methodology in the Community and Family Medicine clerkship, as discussed earlier. Unlike “traditional” Balint groups which focus on physicians working through “difficult patient” experiences, these efforts centered on learners, allowing students space to decompress from patient care during rotations, and circling back to many big questions and tough issues related to psychosocial wellbeing, role modeling, neglect or abuse during rotations, the roles of individuals on medical teams, social and structural inequality as manifested in clinical settings, and death/dying. This clerkship director expertly facilitated such conversations, using digital technologies to foster connections between students in clerkships across the country. This represented a turn toward new models of “safe spaces” and forms of supportive hierarchy without intimidation or fear.

With respect to power, hierarchy, and vulnerability, the psychiatry rotation (usually in third year) and a fourth-year course focused on health, society, and the physician stood out as more egalitarian clinical and didactic moments, revealing that hierarchy is not necessary or inevitable. In the psychiatry rotation, when medications and diagnoses were being discussed, even the new medical students made suggestions that were valued and, as appropriate, incorporated into patient care. In this setting, it was difficult to discern who was “in charge.” Everyone contributed, and everyone’s thoughts were considered. This included the attending physician, medical and nursing students, residents from different disciplines (physician, nurse practitioner, and physician assistant), as well as allied health providers (social work, nurse). In the fourth-year course, faculty guided students through reflective writing exercises that modeled vulnerability and emotional intelligence. This course also created some explicit space for developing what Metzl and Hansen (2014) describe as “structural competency”: unpacking the socioeconomic, political, and policy-oriented realities that shape health outcomes.

Experiences of addressing social difference that led toward deep listening, new forms of empathy, and models for practicing medicine through uncertainty emerged with particular grace and insight from a program that shined a light on patients and families. While not overtly about “diversity,” the program demanded heightened student and faculty attentiveness to language, listening, and lived experience. This program was first implemented in Pediatrics, where it focused on children living with chronic illness or disability; it was later expanded to Geriatrics. In each case, medical students were invited to have immersive, everyday experiences with patients and families, to write and talk about these experiences through guided reflection, and to have honest, difficult, and often transformative conversations with “the real experts,” as faculty preceptors describe patients and families. Getting out of the clinic or hospital and into homes as part of this process seemed to have a lasting effect.

Though used in different situations and relationships and with distinct ends, communication is one of the unifying themes in this article and within the ethnographic research on which it is based. Each of the above examples illustrates possibilities for more widespread and concrete change in the ways medical education is communicated. Adopting Balint group-type models as places for students to discuss the emotional challenges of patient- and self-care creates opportunities to wrestle productively with “professionalism.” Likewise, medical education may benefit from more explicit discussions—particularly between residents, interns, and attending physicians—about how to navigate productively different skill levels and roles within a medical “team,” including the place of medical students therein. Although strides have certainly been made, continued efforts to unpack and problematize what gets glossed as “cultural competency” remains warranted, and the encouragement of reflexive, humble practice seems paramount. Concomitantly, greater incorporation of structural competency modelsFootnote 8 that shift the emphasis away from traits or behaviors that may at once identify, stigmatize, and potentially pathologize social inequality toward attention to the structural forces that shape health outcomes seems timely and essential. Further medical school faculty development on how to elucidate and address the tenets of the hidden curriculum discussed herein would help prepare the next generation of physicians to engage productively with these issues.