Recruiting general practitioners: The role of the ‘hidden curriculum’

As interest in a general practice career continues to diminish within Australia, identification of factors that influence medical students’ speciality choice is imperative.

Although formal learning is influenced by various aspects of the university curriculum, medical students’ career choice has been demonstrated to be significantly impacted by the ‘hidden curriculum’.^1–3 Hafferty first described this concept in 1998 by outlining a formal, informal and hidden curriculum.³ The formal curriculum is the officially endorsed and intended curriculum; the informal curriculum is the unscripted and interpersonal learning that occurs between students and teaching staff; and the ‘hidden curriculum’ includes the values, influences and implicit sociocultural messaging delivered to students behind the scenes within the organisational structure that can drive perceptions of what is deemed ‘good’ and ‘bad’ medicine.^1–3 The ‘hidden curriculum’ is where potential exposure to negative comments about general practice can influence students’ perspectives and consideration of the speciality that forms the cornerstone of healthcare in Australia.

Medical speciality choice often begins during medical school. Negative comments of specialities can occur from peers and superiors, such as other teaching staff, interns, registrars and consultants. Studies have shown that up to 80% of students have experienced negative comments of various specialities, with up to two-thirds of students stating that it would affect their speciality choice.^4,5 Consequently, up to one-quarter of students will change their speciality choice due to disparaging comments.^5–7 General practice is one of the specialities that often receives negative comments that distort the challenges and demands of different specialities.⁷ This has resulted in students either actively keeping their interest in general practice hidden or providing misleading answers when questioned for fear of being treated differently by peers and mentors.^5,8 These are examples of the ‘hidden curriculum’ that might have contributed to the declining student interest in primary care.⁹

The medical deans of Australia and New Zealand recognise the ‘hidden curriculum’ in their recent report, ‘The doctors our communities need: Building, sustaining and supporting the general practice workforce in Australia and New Zealand’.¹⁰ They advocate ‘all inter-specialty interactions within medical learning environments demonstrate the collegiate respect and professional courtesy’.¹⁰

In the UK, the declining student interest in general practice as a career and the concurrent increasing need for general practitioners (GPs) has led to strategic recommendations from the Medical Schools Council and Health Education England: ‘By choice – not by chance. Supporting medical students towards future GP careers’.¹¹ Box 1 outlines their specific strategies to address the ‘hidden curriculum’. These strategies involve ensuring a strong primary care culture within medical schools, with an academic focus and positive role modelling to facilitate peer encouragement and the expression of student interests. GPs will need to play key roles in the faculty and make significant contributions to the curriculum and assessments. Additional recommendations include exposure to passionate clinicians who can provide more accurate information for students to make informed career decisions.^1,12 There should be a focus to create an environment that encourages teamwork and multidisciplinary care across community-based primary care and hospital-based tertiary care. This will help medical students develop an appreciation for holistic, patient-centred care regardless of the context of care delivery and encourage them to independently discover their own vocational calling.