Yale PA didactic year silent curriculum

The silent curriculum — that is, messages that are transmitted from educators to learners without ever being written down in an official curriculum, and of which the educators are often unaware — has long been a topic of discussion in medical education. While the content of a silent curriculum is not always undesirable, I think it is always deserving of close scrutiny.

As I made my way though the didactic year at the Yale PA program, I tried to listen to its silent curriculum; I knew that some of it I would want to ignore or unlearn, and to do that, I first had to know what it contains.

Here are some messages I received in lectures that I do not wish to carry forward into my academic and professional future. 1

  1. We also had some clinical time during our didactic year, with its own set of messages, but I’m not covering those here.

Individuals invented everything

Important medical discoveries were consistently presented by our lecturers as having been made by a single person. (Usually a white man; minorities, even when they were principal contributors to a healthcare advancement, were not given proper attribution.) No acknowledgement was ever made that this person was a member or the leader of a team.

Not only does this paint an unrealistic picture of how medical discoveries are made, it also creates an unrealistic impression of what constitutes success in healthcare. I found this particularly troubling in the setting of PA education, given the emphasis given to teamwork, collaboration, and interprofessionalism in PA practice.

Patients have no life, unless they work in healthcare

Many patient cases were presented during our lectures. Almost all of them began with the patient’s chief concern and ended with a decision about which intervention (pharmacological or otherwise) to carry out.

While I understand the need for efficiency in delivery of our didactic content, I am troubled when patient’s lives before and after a single healthcare encounter are erased from a formative period of my PA education.

I think that we can do better with minimal time investment. Instead of talking about a “32-year old male presenting with a rash on his forearm”, we can talk about a “32-year old male, a father of three and a baseball fan, presenting with a rash on his forearm”. It doesn’t take much to make our patients more human.

On rare occasions, patients’ lives outside of the clinical encounter were acknowledged. Perhaps their profession was named, even though it was irrelevant to the case; perhaps the impact of their condition on the rest of their live was mentioned.

For example, the patient might have been a “32-year old male PA student who developed a forearm rash on the first day of his first rotation”.

The patients who got this special treatment were almost exclusively clinical healthcare workers. If the rash was on a PA’s arm, or the chest pain in a nurse, or the abdominal pain in an MD, we were sure to know about their profession. But a janitor, or a machinist, or a flight attendant? They didn’t get a mention.

Overtreatment needs no consent

It was definitely great to learn that we should not order unnecessary tests. But the reason given for that? “Because if it comes back positive, then you have to work it up.”

That is not how I intend to practice. Yes, I need to discuss results of unnecessary tests with a patient. And then, if the patient and I (and the rest of the care team, and the patient’s caregivers) arrive at a shared decision that further followup is desirable, then that is the path we will take.

The reason that I don’t want to order unnecessary tests is that they are stressful for the patient, and wasteful of limited healthcare resources.

Sex equals gender

Outside of two lectures specifically dedicated to transgender health, trans people did not exist. Throughout the curriculum, sex and gender were persistently implicitly equated.

“Male patient” always meant cisgender male patient; it always meant the patient had a penis, no ovaries, and testosterone-based endocrinology.

When discussion of risk factors included sex or gender, risk profile of trans people was never mentioned.

Yes, if a medical condition predominantly affects men or women, that is useful to know. Other things that would be useful to know: How does that condition affect trans people? How does this change for trans people currently undergoing medical transition? What about surgical transition?

What I know instead is that trans people are invisible in healthcare — which, arguably, is still useful.

Sex and drugs are shameful

Patient cases presented during our didactic year used a variety of word choices to refer to information that was given to a clinician by the patient. Most commonly, “patient reports”, “patient states”, or “patient admits”.

What did these patients report, state, or admit? They might report cutting their hand. The might state they were exercising when their symptoms began.

But whenever they admitted, they admitted one of two things: they were either using recreational drugs, or they were engaged in an unconventional sexual activity.

Is it any wonder that our patients do not easily confide in us when unconventional sexual activity and use of recreational drugs have to be admitted rather than simply stated?

These messages, put side-by-side, suggest a distressing theme in my healthcare education — where patients’ individuality is systematically erased, patients are equated with their symptoms, and implicit biases easily seep from the broader cultural milieu into settings that, ostensibly, provide care and compassion.

What troubles me is not that we have these specific blind spots; the day we’ll stop having blind spots is the day we stop looking for them.

What does trouble me is that I don’t see how this will change.

Our didactic content is delivered by a large number of lecturers (~ 120 in fall semester alone), most of whom teach only a single lecture to PA students, and who are paid for their research or clinical work, but not for their teaching. Their lectures are rarely reviewed by other faculty, and never reviewed by someone specializing in psychosocial aspects of healthcare.

In this environment of limited feedback and minimal incentives to improve, a few of our faculty have taken it upon themselves to be on the lookout for their blind spots, and to nudge our education in a more compassionate direction. Most haven’t — not, I assume, because they are opposed to a more compassionate healthcare, but because discovery of blind spots benefits from a mindful and collaborative process, and no such process is currently in place for our hundreds of uncompensated lecturers.