PMCCPMCCPMCC

Search tips
Search criteria 

Advanced

 
Logo of jgmeLink to Publisher's site
 
J Grad Med Educ. Dec 2011; 3(4): 503–510.
PMCID: PMC3244316
The Effect of the Hidden Curriculum on Resident Burnout and Cynicism
Martha E. Billings, MD, Michael E. Lazarus, MD, Marjorie Wenrich, MPH, J. Randall Curtis, MD, MPH, and Ruth A. Engelberg, PhD
Corresponding author: Martha E. Billings, MD, VA Puget Sound Health Service Research & Development, 1100 Olive Way, Suite 1400, Seattle, WA 98101, 206.277.4150, mebillin/at/u.washington.edu
Received February 18, 2011; Revised July 20, 2011; Accepted July 28, 2011.
Introduction
Residents learn and participate in care within hospital cultures that 5 tolerate unprofessional conduct and cynical attitudes, labeled the “hidden curriculum.” We hypothesized that this hidden curriculum 5 have deleterious effects on residents' professional development and investigated whether witnessing unprofessional behavior during residency was associated with burnout and cynicism.
Methods
We surveyed internal medicine residents at 2 academic centers for 3 years (2008–2010). Hidden curriculum items assessed exposure to unprofessional conduct. We used regression analyses to examine if hidden curriculum scores were associated with cynicism and the Maslach Burnout Inventory depersonalization and emotional exhaustion domain scores.
Results
The response rate was 48% (337 of 708). In the 284 surveys analyzed, 45% of respondents met burnout criteria and had significantly higher hidden curriculum scores (26 versus 19, P < .001) than those not meeting criteria. In cross-sectional analyses, the hidden curriculum score was significantly associated with residents' depersonalization, emotional exhaustion, and cynicism scores. Cynicism scores were also associated with burnout.
Conclusions
Exposure to unprofessional conduct was associated with higher burnout and cynicism scores among internal medicine residents. We also found that cynicism and burnout were significantly associated and 5 be measures of similar but not necessarily identical responses to the challenges posed by residency. Measuring the hidden curriculum and cynicism 5 provide direction for educators attempting to reform hospital culture and improve resident well-being.
Professionalism is a priority within medical education. The American Association of Medical Colleges (AAMC) Group on Educational Affairs and the Accreditation Council for Graduate Medical Education (ACGME) have worked to assess professionalism, identifying areas for research and implementation.1,2 Yet, frequent value conflicts remain between the ideals of professionalism and the “hidden curriculum,” the unintended messages conveyed by faculty, staff, and senior residents in teaching hospitals, and the resulting unprofessional culture conveyed to learners.3,5
During medical school, nearly all students report observing unethical and unprofessional behavior6,7 and describe participating in what they considered unethical behavior.8 They also demonstrate less empathy, more cynicism, and a decline in humanitarianism.6,9,11 These findings suggest that the hidden curriculum 5 have a damaging impact on medical students' professional development.
The impact of residency training on residents' professionalism is less well established. Residency training is a time of intense demands during which residents are immersed within hospital culture. Professional values of altruism, integrity, and empathy 5 be supplanted by efficiency, cynicism, and detachment.12,14 One study15 showed an increase in unprofessional behaviors after internship. Because moral behaviors and attitudes are often situation-sensitive, residents 5 be “deprofessionalized” in these stressful working conditions.16
This learning environment 5 also impact residents' personal well-being. Burnout, operationally defined as a syndrome of emotional depletion and maladaptive detachment after prolonged occupational distress,17 has an estimated prevalence of 50% to 76% among residents.18 It is associated with lower empathy, poorer patient care, and increased perceived medical error.19,20 Medical student burnout has been associated with more unprofessional behavior.21 Perceived mistreatment is also common; residents 5 feel abused, belittled, and humiliated by those in authority.14,22 These experiences, as well as observations of unprofessional conduct and cynicism, 5 contribute to the indifference and emotional fatigue characteristic of burnout.
The relationship between the hidden curriculum and resident burnout and cynicism has not been explored. In this study, we sought to assess whether the hidden curriculum is associated with burnout and cynicism among internal medicine residents. We piloted 2 measures: (1) a hidden curriculum scale and (2) a cynicism scale. Our operational definition of cynicism included an attitude of pessimism and disillusionment related to, yet distinct from, the detachment of burnout. To provide some construct validation for the cynicism scale, we evaluated the association between burnout and cynicism.
Design and Participants
We conducted a survey of postgraduate year (PGY)–1 through 3 (PGY-1 through PGY-3) internal medicine residents at the University of Washington (UW) (N  = 157 in 2008, N  = 167 in 2009, and N  = 168 in 2010) and the University of California, Los Angeles Medical Center (UCLA) (N  = 106 in 2009, N  = 108 in 2010). We contacted residents (N  = 708) via e-mail to complete a 10-minute online survey at UW in 2008–2010 and at UCLA in 2009–2010. Survey responses were anonymous and coded to allow matching of subjects over time. A $5 coffee card or online gift certificate was offered as incentive via a separate form. The University of Washington Human Subjects Division and the Internal Review Board at the University of California, Los Angeles, approved our study.
What was known
Unintended messages in the learning and care environment, termed the ”hidden curriculum,” have a negative effect on learners' professional development.
What is new
Residents exposed to what they perceived as unprofessional conduct scored higher on measures of burnout and cynicism.
Limitations
Sample from 2 institutions, low response rate, potential for response bias.
Bottom line
Assessing the presence and impact of the hidden curriculum 5 improve resident will-being.
Measures
We developed survey items from an extensive review of the literature, and information and measures obtained from professional organizations, such as the AAMC Assessment of Professionalism Project,1 the ACGME Advancing Education in Medical Professionalism,2 and the American Board of Internal Medicine Project Professionalism,23,24 and focus groups that reviewed item content, usability, and feasibility.25 We conducted 2 focus groups in early 2008 with 15 internal medicine residency graduates. The questionnaire is provided as online supplemental material.
The Hidden Curriculum
We adapted our 20-item questionnaire from the surveys of Baldwin et al concerning intern experiences.22,26 Items included reports of (1) perceived humiliation (5 items); (2) observed unprofessional conduct by faculty and residents (11 items); and (3) witnessed falsification of the medical record (4 items) during the past year of training. All items used a 5-point Likert scale (1  = never to 5  = 6 or more times). We summed all endorsed items into a total hidden curriculum score (0–80), with higher scores indicating more observed unprofessional conduct. The scale had a Cronbach α of 0.89. PGY-1 residents had just begun their residencies at the time of the survey and did not complete this questionnaire.
Burnout
We used 2 domains from the Maslach Burnout Inventory (MBI) to assess burnout: depersonalization (MBI-D) and emotional exhaustion (MBI-EE).17 These MBI domains have been validated in previous studies of resident burnout.18,20,28 Five items measure depersonalization and 9 items measure emotional exhaustion. Both domains use a 7-point Likert scale (1  = never to 7  = daily) and 5 be scored either continuously or dichotomously. Burnout was defined as an MBI-D score greater than 9 or an MBI-EE score greater than 26 as in prior studies.20,21,27
Cynicism
As there was no validated tool measuring the construct of cynicism in internal medicine, we created a new 5-item instrument. Questions were developed from preliminary findings of a qualitative study investigating cynicism among medical students, residents, and faculty in academic medicine (Molly Blackley Jackson, MD, University of Washington, personal communication, 4 16, 2008). Four of the questions used a 6-point Likert scale (1  = never to 6  = constantly). One item used a 7-point Likert scale (1  = never to 7  = daily). We standardized the responses to range from 0 to 5 in both instances and summed the items to create a total cynicism score (0–25). Higher scores reflected a higher degree of cynicism; the Cronbach α was 0.81 in our sample.
Analysis
To avoid bias, we selected 1 survey for respondents with multiple surveys. We examined hidden curriculum, burnout subscales (MBI-D and MBI-EE), and cynicism scores descriptively and with bivariate analyses, testing for associations with the following covariates: year of training, site, sex, and survey year. We also compared hidden curriculum and cynicism scores by burnout status (yes/no). For all the bivariate associations, we used Mann-Whitney tests to account for nonnormal distributions.
To assess for associations between the hidden curriculum and each outcome (MBI-D and MBI-EE, cynicism scores) for PGY-2 and PGY-3 residents, we used multivariate linear regression with robust standard errors, controlling for year of training, site, sex, and survey year. We used similar multivariate regression models to evaluate the association of cynicism with continuous MBI-D and MBI-EE scores, using data from all residents.
A total of 337 of 708 (48%) eligible residents completed the online survey and 284 (43%) surveys were selected for analyses. Most respondents were from UW (66%, 187 of 284) owing to the extra year of recruiting and a larger training program at that site (table 1). Response rates were greater at UCLA (57%, 121 of 214), from PGY-1 residents (54%, 149 of 275) and in the second survey year (50%, 137 of 276). Sex distribution was similar to that of the study population.
TABLE 1
TABLE 1
Demographic Characteristics of Internal Medicine Residents (n  = 284)
Description of Hidden Curriculum Exposure and Bivariate Associations
Respondents reported exposure to unprofessional conduct by faculty, peers, and staff (table 2): more than two-thirds felt humiliated by nurses (n  = 115) and by patients (n  = 113) and witnessed residents being disrespectful to patients (n  = 114). A third (n  = 51) witnessed faculty demean another service or specialty on 4 or more occasions. The mean total hidden curriculum score was 23.5 (standard deviation [SD], 13.6; n  = 159). The hidden curriculum score did not differ by year of training, sex, or survey year but varied significantly by site (20.3 versus 27.6, P  = .001, table 3).
TABLE 2
TABLE 2
Hidden Curriculum Item Endorsements by Postgraduate (PGY)-2 and PGY-3 Residents (n  = 166)
TABLE 3
TABLE 3
Comparison of Survey Scores
Description of Burnout Scores and Bivariate Associations
The MBI-D mean was 9.1 (SD, 5.3; n  = 281) and the MBI-EE mean was 21.7 (SD, 11.0). Maslach Burnout Inventory subscores did not differ significantly by training year, site, sex, or survey year. Forty-five percent (127 of 281) met burnout criteria with either an MBI-D score greater than 9 or an MBI-EE score greater than 26. The frequency of respondents meeting these criteria did not differ significantly by training year, site, sex, or survey year. Hidden curriculum scores and cynicism scores were significantly higher for respondents meeting burnout criteria than for those who did not (table 3).
Description of Cynicism Scores and Bivariate Associations
More than half (n  = 154) of respondents reported that they “often” to “constantly” heard cynical comments about internal medicine from colleagues and peers (table 4). The mean cynicism score was 10.7 of 25 (SD, 4.6; n  = 279). Cynicism scores did not differ significantly by training year, site, or survey year. Men had significantly higher cynicism scores than women (11.7 versus 9.9, P  = .001).
TABLE 4
TABLE 4
Cynicism Scale Item Endorsements by Postgraduate (PGY)-1, PGY-2, and PGY-3 Residents (n  = 284)
Multivariate Associations Between Hidden Curriculum Exposure, Burnout, and Cynicism
In multivariate linear regressions adjusted for year of training, site, sex, and survey year, the hidden curriculum score was positively associated with depersonalization (MBI-D), emotional exhaustion (MBI-EE), and cynicism scores (table 5A). Cynicism scores were significantly associated with MBI-D and MBI-EE scores (P < .001, table 5B) and sex was a significant covariate, with women scoring higher on the MBI-EE domain than men.
TABLE 5A
TABLE 5A
Association Between Hidden Curriculum Scores, Burnout, and Cynicism for Postgraduate (PGY)-2 and PGY-3 Residents (n  = 166)a,b
TABLE 5B
TABLE 5B
Association Between Burnout and Cynicism for Postgraduate (PGY)-1, PGY-2, and PGY-3 Residents (n  = 284)a,b
Unprofessional conduct by resident colleagues and faculty conveys a hidden curriculum that contradicts professional standards and 5 undermine physician ideals. Consistent with prior studies,22,26 respondents reported frequently observing fellow residents engaging in unprofessional conduct. As residents are role models for interns and medical students,12 witnessing residents being disrespectful 5 dehumanize patients11 and perpetuate an unprofessional culture.28 We also found that residents and faculty were frequently observed criticizing other specialty services. This 5 be a pervasive characteristic of academic medical culture and 5 foster cynical attitudes.12 Finally, respondents felt humiliated frequently by nurses and patients, suggesting unprofessionalism has societal roots beyond physicians.
Previous studies suggest that cynicism is a prevalent feature of medical culture11,13,29,30 and 5 have significant consequences for physicians' behaviors and attitudes.31 Furthermore, cynicism 5 result in loss of empathy and decreased humanism,10 traits needed to form strong patient-physician relationships.31 Our findings suggest that cynicism 5 be socialized through the hidden curriculum.28 The 5-item tool we used to measure cynicism performed well, demonstrating expected strong correlation with depersonalization and internal consistency. This instrument requires further psychometric testing and validation to ensure that it measures the construct of cynicism and to confirm its relationship to burnout.
Residents who met burnout criteria witnessed significantly more unprofessional behavior overall than those who did not. These data suggest that an unprofessional learning environment is associated with resident distress. Previous studies18,27 have identified feelings of lack of control, loss of autonomy, and stressful work relationships as contributors to burnout. A recent study of medical students showed a correlation between burnout scores (MBI-EE and D) and poor professional climate scores,32 supporting our findings. The professionalism climate instrument functions much like our hidden curriculum measure, assessing observed behavior of faculty, residents, and students. The atmosphere created by unprofessional comments and cynical attitudes 5 impact residents' well-being, leading to increased detachment. Alternatively, residents who meet criteria for burnout 5 perceive their environment more negatively, creating a “toxic” learning environment. Lower empathy scores, a construct related to cynicism, also correlated with a poorer professional climate among medical students.32 This supports our results showing an association between unprofessional conduct and increased cynicism.
Cynicism and burnout were also highly associated, perhaps reflecting related constructs. In our operational definitions, we have attempted to differentiate these constructs, defining cynicism as a pessimistic view of medical care and burnout as a detached approach to patient care. However, this differentiation 5 be arbitrary. Rather than a coping response to the stresses of residency and protecting from burnout,33 cynicism 5 overlap with the construct of burnout and arise in response to similar job stresses and challenges.
This study has a number of limitations. First, the sample is drawn from only 2 academic institutions with a low response rate. Response bias 5 have significantly affected the results, with burnout likely affecting participation rates. Second, the hidden curriculum and cynicism instruments have not been validated and require additional testing. Professionalism, although extensively studied, is difficult to measure; there are few validated, reliable instruments.34 Our survey was developed and implemented before publication of the professionalism climate instrument, which appears to gather similar data about the learning environment in medical school.35 Our study establishes a similar promising instrument focusing on witnessed and experienced unprofessional conduct in residency. Further psychometric evaluation of our instrument and comparison with the professionalism climate instrument is necessary. Third, many of the survey items relied on recall of experiences during a prior year, which is subject to recall bias and 5 be influenced by resident well-being. The survey assesses 1 point in time; responses to burnout and cynicism questions likely vary, depending on residents' rotations and on other life stressors we did not explore. Finally, this cross-sectional analysis can only demonstrate associations, not causality.
Our data demonstrate an association between the hidden curriculum—that is, exposure to unprofessional behaviors—and measures of resident burnout and cynicism. We found that cynicism and burnout were also significantly associated and 5 be measures of similar but not necessarily identical behavioral responses to the challenges posed by residency. Measures that appropriately assess unprofessional behaviors and residents' responses to these behaviors 5 help in the development and evaluation of interventions to reduce these behaviors and their effect on residents. These instruments 5 serve as a first step toward reforming institutional culture and preventing the development of disillusioned, detached, and unprofessional residents. Further studies are needed to assess whether a more humanistic culture leads to greater compassion, empathy, and enhanced resident well-being in an effort to achieve the goal of training physicians who demonstrate the values of professionalism.
Footnotes
Martha E. Billings, MD, is Senior Fellow, Health Service Research & Development, Department of Veterans Affairs, Puget Sound Health Care System, and Division of Pulmonary Critical Care Medicine, Department of Medicine, University of Washington; Michael E. Lazarus, MD, is Assistant Program Director, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles; Marjorie Wenrich, MPH, Vice-Chair, Office of the Dean, School of Medicine, University of Washington; J. Randall Curtis, MD, MPH, is Professor, Division of Pulmonary Critical Care Medicine, Department of Medicine, University of Washington; and Ruth A. Engelberg, PhD, is Associate Professor, Division of Pulmonary Critical Care Medicine, Department of Medicine, University of Washington.
Funding: This study was supported by a grant from the Western Group on Educational Affairs, a chapter of the Association of American Medical Colleges. Dr Billings received initial support from a T32 training grant (NIH-HL07287). This material is based upon work supported (or supported in part) by the Department of Veterans Affairs, Veterans Health Administration, Office of Research and Development and Health Services Research and Development (HSR&D). Dr Billings is currently supported by a HSR&D MD Postdoctoral Fellowship (TMP 61-038). Dr Curtis was funded by a K24 Award from that National Heart Lung and Blood Institute (K24 HL068593).
The authors wish to thank the internal medicine residency programs at the University of Washington and University of California, Los Angeles, for their support for this project; the Clinical Research Works in Progress group for their review of the survey; and the Division of Pulmonary Critical Care Medicine at the University of Washington for their initial support of the study incentives.
Portions of this study were presented in abstract form at the American Thoracic Society International Conference, New Orleans, Louisiana, in 5 2010.
The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs, the US Government, or the funding agencies.
1. Group on Educational Affairs. Assessment of Professionalism Project. https://www.aamc.org/download/77168/data/professionalism.pdf. Published 2002. Accessed 7 15, 2011.
2. Accreditation Counsel for Graduate Medical Education. Advancing education in medical professionalism: an educational resource from the ACGME Outcome Project. http://www.acgme.org/outcome/implement/Profm_resource.pdf. Published 2004. Accessed 7 15, 2011.
3. Hafferty FW. Beyond curriculum reform: confronting medicine's hidden curriculum. Acad Med. 1998;73(4):403–407. [PubMed]
4. Stern DT, Papadakis M. The developing physician—becoming a professional. N Engl J Med. 2006;355(17):1794–1799. [PubMed]
5. Stern DT. Practicing what we preach: an analysis of the curriculum of values in medical education. Am J Med. 1998;104(6):569–575. [PubMed]
6. Feudtner C, Christakis DA, Christakis NA. Do clinical clerks suffer ethical erosion: students' perceptions of their ethical environment and personal development. Acad Med. 1994;69(8):670–679. [PubMed]
7. Christakis DA, Feudtner C. Ethics in a short white coat: the ethical dilemmas that medical students confront. Acad Med. 1993;68(4):249–254. [PubMed]
8. Reddy ST, Farnan JM, Yoon JD, et al. Third-year medical students' participation in and perceptions of unprofessional behaviors. Acad Med. 2007;82((10 suppl)):S35–S39. [PubMed]
9. Newton BW, Barber L, Clardy J, Cleveland E, O'Sullivan P. Is there hardening of the heart during medical school. Acad Med. 2008;83(3):244–249. [PubMed]
10. Dyrbye LN, Thomas MR, Shanafelt TD. Medical student distress: causes, consequences, and proposed solutions. 5o Clin Proc. 2005;80(12):1613–1622. [PubMed]
11. Wear D, Aultman JM, Varley JD, Zarconi J. Making fun of patients: medical students' perceptions and use of derogatory and cynical humor in clinical settings. Acad Med. 2006;81(5):454–462. [PubMed]
12. Brainard AH, Brislen HC. Viewpoint: learning professionalism: a view from the trenches. Acad Med. 2007;82(11):1010–1014. [PubMed]
13. Coulehan J. Viewpoint: today's professionalism: engaging the mind but not the heart. Acad Med. 2005;80(10):892–898. [PubMed]
14. Collier VU, McCue JD, Markus A, Smith L. Stress in medical residency: status quo after a decade of reform. Ann Intern Med. 2002;136(5):384–390. [PubMed]
15. Arora VM, Wayne DB, Anderson RA, et al. Changes in perception of and participation in unprofessional behaviors during internship. Acad Med. 2010;85((10 suppl)):S76–S80. [PubMed]
16. Lopez L, Katz JT. Perspective: creating an ethical workplace: reverberations of resident work hours reform. Acad Med. 2009;84(3):315–319. [PubMed]
17. Maslach C JS, Leiter MP. Maslach Burnout Inventory Manual. 3rd ed. Palo Alto, CA: Consulting Psychologist Press; 1996.
18. Thomas NK. Resident burnout. JAMA. 2004;292(23):2880–2889. [PubMed]
19. West CP, Huschka MM, Novotny PJ, et al. Association of perceived medical errors with resident distress and empathy: a prospective longitudinal study. JAMA. 2006;296(9):1071–1078. [PubMed]
20. Shanafelt TD, Bradley KA, Wipf JE, Back AL. Burnout and self-reported patient care in an internal medicine residency program. Ann Intern Med. 2002;136(5):358–367. [PubMed]
21. Dyrbye LN, Massie FS, Jr, Eacker A, et al. Relationship between burnout and professional conduct and attitudes among US medical students. JAMA. 2010;304(11):1173–1180. [PubMed]
22. Daugherty SR, Baldwin DC, Jr, Rowley BD. Learning, satisfaction, and mistreatment during medical internship: a national survey of working conditions. JAMA. 1998;279(15):1194–1199. [PubMed]
23. Arnold EL, Blank LL, Race KE, Cipparrone N. Can professionalism be measured: the development of a scale for use in the medical environment. Acad Med. 1998;73(10):1119–1121. [PubMed]
24. American Board of Internal Medicine Foundation. Advancing medical professionalism to improve health care. http://www.abimfoundation.org/. Published 2001. Accessed 7 15, 2011.
25. DeVon HA, Block ME, Moyle-Wright P, et al. A psychometric toolbox for testing validity and reliability. J Nurs Scholarsh. 2007;39(2):155–164. [PubMed]
26. Baldwin DC, Jr, Daugherty SR, Rowley BD. Unethical and unprofessional conduct observed by residents during their first year of training. Acad Med. 1998;73(11):1195–1200. [PubMed]
27. Prins JT, Gazendam-Donofrio SM, Tubben BJ, van der Heijden FM, van de Wiel HB, Hoekstra-Weebers JE. Burnout in medical residents: a review. Med Educ. 2007;41(8):788–800. [PubMed]
28. Mareiniss DP. Decreasing GME training stress to foster residents' professionalism. Acad Med. 2004;79(9):825–831. [PubMed]
29. Testerman JK, Morton KR, Loo LK, Worthley JS, Lamberton HH. The natural history of cynicism in physicians. Acad Med. 1996;71((10 suppl)):S43–S45. [PubMed]
30. Goldie JG. The detrimental ethical shift towards cynicism: can medical educators help prevent it. Med Educ. 2004;38(3):232–234. [PubMed]
31. Adler HM. The sociophysiology of caring in the doctor-patient relationship. J Gen Intern Med. 2002;17(11):874–881. [PubMed]
32. Brazeau CM, Schroeder R, Rovi S, Boyd L. Relationships between medical student burnout, empathy, and professionalism climate. Acad Med. 2010;85((10 suppl)):S33–S36. [PubMed]
33. Wear D, Aultman JM, Zarconi J, Varley JD. Derogatory and cynical humour directed towards patients: views of residents and attending doctors. Med Educ. 2009;43(1):34–41. [PubMed]
34. Veloski JJ, Fields SK, Boex JR, Blank LL. Measuring professionalism: a review of studies with instruments reported in the literature between 1982 and 2002. Acad Med. 2005;80(4):366–370. [PubMed]
35. Quaintance JL, Arnold L, Thompson GS. Development of an instrument to measure the climate of professionalism in a clinical teaching environment. Acad Med. 2008;83((10 suppl)):S5–S8. [PubMed]
Articles from Journal of Graduate Medical Education are provided here courtesy of
Accreditation Council for Graduate Medical Education