This last statement captures the essence of the hidden curriculum. It is not surprising that Ginsburg and colleagues6
found themes like: “do what you’re told;” these themes are congruent with underlying messages, such as “hierarchy is necessary,” that exist in the organizational cultures of medical schools. It also makes sense that the attendings in Ginsburg and colleagues’ study expected students to automatically know what to do; when one is embedded in a culture, the culture itself is very hard to see or articulate. Rather, one feels
the culture, like an invisible hand that guides one’s actions.
There is a recurring discussion in which I have been fortunate to be included at my institution and several others. It centers on what to do about a perceived crisis of professionalism among students. It typically ends up with some kind of strategy to identify and remediate the students who are either behaving unprofessionally, or are at risk for behaving unprofessionally. I once suggested that perhaps a parallel structure should be built to identify system issues that created opportunities for students to behave unprofessionally. The suggestion did not go over well. The fact remains that culture change is difficult, complex, unpredictable, and slow to evolve. It takes time to articulate what you can only at first feel. However, the system contains both powerful inhibitors and enablers of professionalism. Exciting work at the University of Indiana11
and elsewhere is attempting to understand and harness such enablers to create a lasting effect on the professional attitudes and behaviors of those who live and work in the system. Stark and colleagues’ work in this issue of JGIM7
demonstrates the promise that such system-based interventions can have for improving faculty feedback, a notoriously difficult process to change. My dream is that while the educational community struggles to learn how to assess and foster, on an individual level, such virtues as altruism and compassion, we will also engage in conversations aimed at defining how such virtues are realized at the level of a hospital, or a healthcare network, or the US healthcare system. For example, what would an “altruistic hospital” look and function like? What would it feel like to be a physician in such a hospital?
Clearly, there is much to be done when it comes to the topic of professionalism. The exciting work in this issue of JGIM points toward several directions in which the field is moving. My hope is that funding agencies, foundations, and the general public will have as much interest and stake in this topic as the scholarly community already does. Amid all of the technological advances occurring on an almost daily basis, the subject of professionalism is critically important, because it holds the potential to chart where healthcare has been, and where it is headed.