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The Unspoken Curriculum

Many of my viewers write me to ask, "Stuart, what's the unspoken curriculum? Why do I feel so clueless on the wards?" The unspoken curriculum, I tell them, refers to the life lessons students learn as they become accepted as equals into the practice of medicine.

Sometimes students find themselves unprepared as they are tested on the unspoken curriculum during their clerkship years. The following are true stories from actual medical students, though the names have been changed and the situations fictionalized to protect the innocent (and the not so innocent). Any similarity with real people, living or deceased, is not only coincidental, but scary.

Jon R. Writes:

"Stuart, I feel like such a naive nut-head. I just recieved my first clerkship evaluation back and I feel it didn't reflect my outstanding performance or the ubiquitous praise I received from housestaff and attendings I worked with during my rotation.

Early during the four weeks of my surgical sub-specialty rotation, I came to realize that even though it was my first rotation, it was a field I was passionate about, and which I was strongly considering entering. I could not have worked any harder or showed any more enthusiasm than I did for this rotation.

I pre-rounded on my patients at 3am, and left the hospital around 8pm, after I had looked up the H&P's of all my cases for the following day. I drew detailed anatomical drawings of all the fascial planes and muscle layers for each case the preceeding night, and brought them into the OR during my cases. I read volumes of books about the pathophysiology of my patients. In my spare time, I prepared a 45 minute talk about the unique disease of one of the six patients I happened to be carrying, and subsequently wrote the case up for publication in the Stanford Journal.

The housestaff and attendings could not have been more encouraging with their praise. 'We love having you on our service. You have truly been a help.' 'We need to convice you to go into our specialty, Jon," one of the attendings told me as I finished my last week.

Which brings me to why I feel like such a nut-head. This was the extent of my evaluation, "Jon was a very good student. He did, however, ask simplistic and inappropriate questions at times, which may be due to his lack of clinical experience. His enthusiasm, however, was impressive."

Stuart, I was told that the only thing that matters on the wards is ENTHUSIASM, and a willingness to learn. And what about that old saying which everyone kept telling me, "There's no such thing as a stupid question?" I guess, there are only "simplistic and inappropriate ones, then."

Stuart, what could I have done differently?"

Stuart Answers:

Well, first of all Jon, you need to be able to say, "I'm naive, but that's okay‚I'm entitled to my naiveity." Now that you've been put in this situation, try to learn from it and ground your expectations.

You need to try to keep in mind that, in the end, what truly matters is what you think of yourself. If you are seeking external validation of your self-worth, then Jon, let me be the first to tell you that surgery may not be the ideal specialty for you.

What you describe is very common among medical students, and is what many students find to be one of the most surprising aspects of the "unspoken curriculum" of medical school. Clerkship evaluations may not always reflect the degree of effort or accomplishment that you feel you achieved during a rotation.

This tends to be especially true for beginning clinical medical students, who are used to achieving high test scores from the basic sciences curriculum. Clinical evaluations tend to be more subjective. Worse still, they may not even include comments from attendings you have worked with. Some students have also commented that they tend to be judged to a "higher" standard, even though they are just beginning on the wards and do not have much if any clinical knowledge.

Follow this simple advice, Jon, and you will become a superb doctor; "learn for the sake of learning, to feed your curiosity, and to engage your mind." Learning on the wards is no longer a passive environment where everything you need to know is found in the course syllabus. You must seek knowledge. You must question facts. You must find your own truth.

Any, yes Jon, there is NO such thing as a STUPID question. There are, however, inappropriate times to ask questions, such as during busy clinics where there is a large backlog of patients. Save your questions for later, or during dead times when you are alone with your team.

If anyone ever suggests to you that you should not be asking questions, no matter how simplistic, then it is my opinion that they are hindering your education and may not truly wish to teach. If this happens, simply find another attending our housestaff member who truly understands that the mission of an academic medical center, such as Stanford, is to nurture the next generation of America's doctors.

Dr. Wolfe in the OSA is also a strong advocate for medical students. He should be one of the first people you speak with regarding this situation, since it may be possible that your evaluation was completed incorrectly and should be sent back to the clerkship office. He can also help you put things into perspective.

Because, Jon, it seems to me that you have a passion for learning. Keep it up, despite what others may say and you will be a superb doctor.

And remember, you're good enough, you're smart enough, and gosh darn'it people like you!