The ‘worthy’ patient: rethinking the ‘hidden curriculum’ in medical education

Abstract

This paper examines how physicians determine the quality and quantity of time to devote to each patient, and how these decisions are taught to physicians-in-training as part of the 'hidden curriculum' in medical education. The notion of moral economy is used to analyze how judgments of patient worth come to guide and influence interactions among physicians and physicians-in-training and patients, and how these interactions impact medical care. However, this paper also questions the notion of the hidden curriculum as a static or reified concept. Instead, the paper uses participant narratives to show how physicians-in-training are not simply passive recipients of the hidden curriculum but also actively resist judging patients based on perceptions of worth, even as they learn to operate within a moral economy of care.

Humanism, the Hidden Curriculum, and Educational Reform

“…18,19 Today, the concept of the HC is applied to a wide variety of educational settings. 1, [20][21][22] Issues using this lens stretch from admissions to accreditation and from the topic of the educational experience and professional identity formation to more point-specific topics such as CME, 23 faculty development, 24 the creation of the "worthy patient," 25 and the production of heteronormativity during medical education leading to the privileging of heterosexuality and the marginalization of LGBTQ orientations. 26 Scholarly work using the HC as an analytic lens remains more entrenched within education than sociology.…”

‘Good’ patient/‘bad’ patient: clinical learning and the entrenching of inequality

“…Messages about the good and the bad patient are a part of the hidden and informal curricula (Hafferty , Hafferty and Hafler , Higashi et al . , O'Donnell ) of medical school. Embedded in the hidden curriculum are also ‘professional feeling rules’ (Burkitt : 139) shaped, in part, through an emphasis on ‘affective neutrality’ (Smith and Kleinman : 57).…”

“…: 142), instructs medical students on patient worth (Higashi et al . ). Further, perceptions of patients that are based on a ‘moral economy’ of ‘values, behavioral norms and ethical assumptions’ matter greatly in guiding interaction with patients and decisions about their care (Higashi et al .…”

“…Further, perceptions of patients that are based on a ‘moral economy’ of ‘values, behavioral norms and ethical assumptions’ matter greatly in guiding interaction with patients and decisions about their care (Higashi et al . : 13). Much research has shown that clinician perceptions of patients draw from a repertoire of social stereotypes with understandings of patient character and capacity also featuring centrally in uneven access to health care (Barr , Feagin and Bennefield , Roberts , Street et al .…”

Patient engagement at the margins: Health care providers' assessments of engagement and the structural determinants of health in the safety-net

“…Distributing care according to assessments of patient engagement—directing care towards engaged patients and withdrawing care from unengaged patients—holds the possibility of establishing a form of health care “deservingness” (Willen 2012) based on providers’ perceptions of who legitimately desires to achieve better health. Health care providers draw from often-implicit ethical norms that define which patients are “worth” their time and effort, and tend to privilege patients who are more agreeable and have seemingly “fixable” problems (Higashi et al 2013). Further, racial minorities and socioeconomically disadvantaged patients are more likely to be labeled as non-compliant and to be seen as refusing care (Maskovsky 2005, Rouse 2010).…”