Social context matters in medical teaching and health care

In the March issue of Academic Medicine, researchers from the Weill Cornell Division of Medical Ethics draw upon a sociological theory of high- and low-context societies to explain how forces beyond the medical school can influence education in the classroom and at the bedside. Low-context societies, as in the West, are typified by a lack of implicit cultural clues and an "excess" of signage directing both the inhabitant and the visitor on their way. The authors contrast cultural patterns in these low-context societies -- where even the exit sign is labeled as an exit sign -- with high-context societies, as would be seen in the Middle East. High-context societies have a paucity of these external clues and information is implicit and hidden.

The authors build upon this sociological theory to discuss the "hidden curriculum" in medical education -- a topic of great interest to medical educators. The hidden curriculum is not what is formally taught but what practices and norms are picked up in the lab or the wards, where students emulate behaviors that they see, not necessarily what has been taught or what is written in the textbooks.

By contrasting the student's experience in high-context Doha, where much information is culturally embedded and seemingly hidden, with low-context New York, where information is made more overt, the authors theorize that in each setting, the proportion of implicit and explicit curricular elements is determined by the extramural cultural environment.

The authors, Dr. Joseph Fins, the E. William Davis Jr., M.D. Professor of Medical Ethics, chief of the Division of Medical Ethics and professor of medicine, professor of public health and professor of medicine in psychiatry at Weill Cornell Medical College, writing from New York, and Dr. Pablo Rodriguez del Pozo, associate professor of public health, writing from Doha, came to their conclusions after teaching the same clerkship in clinical ethics and palliative care at their respective campuses of the Weill Cornell Medical College in New York and in Doha, Qatar.

"We have gained a tremendous amount of insight into medical education by teaching in different countries, and what we find is that medical educators, beyond a vague notion of being culturally sensitive, need to understand the degree that social context matters," says Dr. Fins.

"In a high-context society such as Doha, much more is hidden than in low-context New York," Dr. Fins adds. "Because of this, much more of the curriculum is outside the realm of the structured curriculum and hence implicit, by virtue of the society in which it is delivered."

Dr. Rodriguez del Pozo notes that "In medical education, we can appreciate the true weight of the hidden curriculum when we export our programs abroad." He adds, "We don't want the quality and effectiveness of the explicit curriculum to be compromised by underestimating the effects of the hidden curriculum bolstered by local forces."

In an important message for their fellow educators, Drs. Fins and Rodriguez del Pozo refute the long-held view that there is a single hidden curriculum and argue that what is hidden or implicit is in large part driven by whether teaching occurs in a high- or low-context setting. Hence there are as many hidden curricula as there are educational settings. "If one is teaching the same curriculum in New York and in Doha, you can't assume the messages being received by the medical students are the same, and we think that is also true domestically given different local customs, history and missions -- that there is no such thing as a single hidden curriculum. There are many," says Dr. Fins, who also serves as director of medical ethics at NewYork-Presbyterian Hospital/Weill Cornell Medical Center and chairs its ethics committee.

This report is a continuation of studies published by the two authors on the differing communication patterns related to informed consent at the two campuses, particularly on the differences between high- and low-context societies. This research has indicated that if communication in high-context societies relies on explicit words rather than on implicit environmental signs, patients paradoxically can become confused and even distrustful.