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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.

Melissa D. Writes:

"Stuart, I'm in such a shame spiral. Things started to go wrong after the first week on my Medicine rotation. Post-call, I was sitting with my team in the resident's lounge reading Harrison's when I heard a loud rattling noise. Startled, I looked up and it was my resident, rattling the empty ice chips in his styrofoam cup. "I'm thirsty, get me some ice water please Melissa," he said, with a totally serious look on his face.

I thought "whatever, this guy has to be joking!"

He wasn't joking. He just stared at me, until I got up, took his cup, and walked away. Stuart, I was so demoralized. Images of Celia from the "Color Purple" flashed through my mind. When I got home, I defrosted a Sara Lee, put on my husband's pajamas and went to bed­for two days.

Needless to say, I was scutted out and bitter for the rest of my rotation. I know I should probably have 'let go' and 'detached' from the situation, but in my mind, I kept thinking of him as a 'horrible, nasty, dysfunctional weenie.' I received a horrible evaluation that month, despite putting in long hours and being a diligent student. The formative comments on my evaluation remarked that I was an "immature" student who wasn't a "team" player.

Stuart, what could I have done differently?"

Stuart Answers:

Well, first of all Melissa, you need to be able to say, "I'm angry, but that's okay­I'm entitled to my anger." Now that you've been put in this situation, try to learn from it and define your boundaries. You must establish in your own mind what are acceptable boundaries for you; between being "helpful" to your team and nurturing a positive learning environment to allowing yourself to be scutted out by others, getting nothing in return. On the wards, you will find that you need to be assertive and stand up for yourself.

Passive-aggressively allowing yourself to be used by your team, while calling them "dysfunctional weenies" behind their backs is simply not productive.

Begin by deciding, for instance, that you are willing to look up journal articles your resident requests from you for his research project, but only if you would benefit from reading the material as well. Otherwise, simply say "I would like to help you out, but first I have to finish reading this chapter in Harrison's for lecture tomorrow. If I have time at the end of the day, I will try to help you out." If he continues to request you to perform inappropriate duties such as fetching him ice water, you need to be assertive and say "I'll fetch it for you this time, if you get it for me next time." Or, more frankly "No, I'm sorry, but I'm also very tired, and have more important things to do."

Finally, contact the chief resident or Dr. Wolfe if these problems persist. Many students mistakenly allow situations to progressively worsen, afraid they will be perceived as "complainers." However you must make others aware of inappropriate behavior if, after your first attempt, you are unable to resolve the situation yourself.