Four main themes emerged: personal encouragement, haphazard teaching, the importance of hierarchy, and getting ahead by being competitive.
Among the 36 students, 26 identified 46 specific staff members as positive role models who had an encouraging and motivating impact on them. These teachers' commitment to teaching and to communicating with students, patients, and colleagues were highly rated. As one student put it:
There have been a couple of lecturers that I have thought were very good... One of them was one of my tutors as well so I got to know them personally, and he's a really nice bloke... good lecturers—approachable and you can chat to them about anything else. (Year 2 student)
Most of the role models mentioned were male doctors (27/46), who were seen particularly valued in relation to their knowledge, professional power, and authority. The female medical role models (19/46) were said to convey more “human” attributes: tolerance, integrity, respectfulness, and support towards students. Only two of the 46 named role models were non-white, although 14 of the 36 students were themselves non-white.
Enthusiastic about her discipline, involved students actively in the work, excellent knowledge and practical skills, nice to patients, staff, and students. (Year 5 student)
Most students (25/36) described the haphazard nature of teaching, particularly by clinical staff, who often disregarded the overt timetable. Twenty students indicated that unscheduled changes to teaching sessions were time wasting and very common. Final year students (6/7) were especially critical of what they perceived as a lack of commitment and poor teaching skills in some teachers. Despite this, most students gave a series of excuses to explain teachers' absence from educational sessions. Often students were profoundly demotivated by their perception that many clinical teachers had a low level of commitment to teaching, and this led to a repetitive cycle of non-attendance by students and teachers alike.
I mean we've had so many days where we've had, sort of, five different sessions scheduled—and no one turns up! You just think, you know, why bother coming in? So that's irritating. It does happen a lot to everyone. I mean, obviously the people who are teaching have another job—it's not their only job to teach you—but it's when you turn up and they don't get somebody else to do it, or they don't even let you know that they haven't turned up. (Year 3 student)
Importance of hierarchy
One of the principal ways in which students learnt about the importance of hierarchy in medicine is through teaching that involved humiliation, a feature noted in previous studies.5,7
In total, 21/36 students reported 29 incidents of humiliation: 10 they had observed or heard about and 19 direct personal experiences, particularly during their clinical years. Almost all the reported perpetrators were male doctors (28/29 incidents). Typically the incidents occurred in ward rounds, when students were unable to answer the same repeated question (11 incidents) or when they were criticised for an inadequate clinical examination (8 incidents). In three quarters of the incidents (21/29) the perpetrators were senior medical staff. Again, students often reported excuses for such behaviour by senior teaching staff or blamed themselves for these events.
I've found my first rotation was very stressful, humiliating, I worked and read because of fear, because of being targeted—and that was just miserable... One time, the consultant came in when I was examining the patient—his registrar was there, his SHO was there and just started asking me questions... I just went blank and didn't know the answers to his questions—and then he got angrier... after things like that... you don't even have the confidence to take blood or anything. (Year 3 student)
There were also several reports of nurses and midwives treating medical students disrespectfully (15/23 clinical students). Such behaviour may indicate a degree of professional rivalry.5,19
When, I think, you go to a teaching hospital, you're again, you know: “Oh, it's a medical student turned up on the wards!” The nurses go: “Cor blimey,” you know, “here's another one!” Some of them actually try and give you a hard time... the midwives especially... they'll fob you off... most male medical students, you know, when they do obs and gynae, they'll have this totally biased opinion of midwives—which I do at the moment as well. They are the women from hell! (Year 5 student)
Getting ahead by being competitive
Half of the students (18/36) reported that competition rather than cooperation is the defining characteristic of medicine, a view that was more common among clinical students (16/23) than non-clinical students (2/13). Related to this, for 13/36 students one “module” of the hidden curriculum concerned the need to impress senior medical staff, which was directly seen to prepare the way for prestigious jobs in the future. More subtly, some students used phrases during the interviews which implied some advantage over other students. For example, 5/9 mature students reported at the beginning of the interview that they already had a degree or professional qualification. A student reflected on this atmosphere:
You notice that students during the clinical years try to stand out, stabbing each other. (Year 3 student)