This chapter provides a broad overview of aspects of hidden curriculum (HC) theory and their implications for medical education. We begin by differentiating between the three primary types of curricula (formal, informal, and hidden) and examine their relative impact on the socialization processes of medical trainees. We then link the rise of a HC literature within medical education to prior work in sociology and education scholarship and spotlight how this more invisible curriculum reflects and perpetuates power relations and hierarchies within health care. We conclude by considering potential implications of HC theory for contemporary initiatives such as interprofessional education, and discuss resilient features of the HC as well as strategies and mechanisms that may assuage its impact on the culture of medical education and medical students’ attitudes and behaviors.

Issues of socialization and the occupational formation of future physicians form an essential foundation for how educators understand and then improve the training of medical students. In this entry, we link early sociological studies of medical school training to the broader conceptual framework of how occupational groups such as medicine ensure that its future practitioners acquire the knowledge, skills, and values that underscore the work of that group. We then explore important conceptual distinctions between occupational and organizational socialization and examine how the structure of training and differences among learning environments help to shape professional identity. We conclude with an overview of current research on medical student socialization and the challenges raised by major initiatives such as longitudinal training, reforming the hidden curriculum, and interprofessional education.

ABSTRACT:Holistic review has been widely adopted in medical education as a means of promoting equity in the application process and diversity in the medical workforce. Artificial intelligence (AI) is a rapidly emerging technology already having an impact on the medical school and residency application process as students and faculty alike increasingly turn to AI tools to automate some steps in the preparation and evaluation of application materials. While AI may have the potential to improve the holistic admissions process by increasing efficiency and adding some measure of standardization among reviewers, the authors caution that this promise does not come without certain pitfalls. AI models may introduce new sources of bias and amplify existing ones, which, when combined with a lack of transparency regarding their use in the admissions process, may perpetuate the very inequities that holistic review seeks to minimize. The authors call for the medical education community to establish clear regulations to govern the acceptable use of AI in the admissions process and for a principled adoption of AI tools in a way that is sustainable for applicants and reviewers in the future.

We delve into the escalating issue of U.S. physician burnout, arguing its roots lie in the proletarianization of the U.S. medical profession—a transition driven by the loss of autonomy and control under the shadow of capitalist systems. This process, aligned with Marx's concept of proletarianization, sees physicians morph from independent practitioners to exploited workers within a wage-labor system controlled by a corporatized U.S. healthcare system. We contend that contemporary factors attributed to U.S. physician burnout—loss of control, emphasis on productivity, increased clerical demands, and a diminishing sense of work's meaning—are not novel but deeply ingrained in the medical profession's socio-historical fabric. By juxtaposing burnout with proletarianization, we highlight macro-level sources of strain and advocate for reevaluating physician work through Marxist theory and, in turn, extend the argument that addressing burnout necessitates moving beyond individual or organizational solutions to encompass broader socio-economic structures as seen through the lens of work exploitation. We conclude by discussing "class consciousness" among U.S. physicians and posit that collective awareness and action could pave the way for substantial reforms for the practice of medicine, the organization of medicine as a profession, and the burnout epidemic among U.S. physicians.

We delve into the escalating issue of U.S. physician burnout, arguing its roots lie in the proletarianization of the U.S. medical profession-a transition driven by the loss of autonomy and control under the shadow of capitalist systems. This process, aligned with Marx's concept of proletarianization, sees physicians morph from independent practitioners to exploited workers within a wage-labor system controlled by a corporatized U.S. healthcare system. We contend that contemporary factors attributed to U.S. physician burnout-loss of control, emphasis on productivity, increased clerical demands, and a diminishing sense of work's meaning-are not novel but deeply ingrained in the medical profession's socio-historical fabric. By juxtaposing burnout with proletarianization, we highlight macro-level sources of strain and advocate for reevaluating physician work through Marxist theory and, in turn, extend the argument that addressing burnout necessitates moving beyond individual or organizational solutions to encompass broader socio-economic structures as seen through the lens of work exploitation. We conclude by discussing "class consciousness" among U.S. physicians and posit that collective awareness and action could pave the way for substantial reforms for the practice of medicine, the organization of medicine as a profession, and the burnout epidemic among U.S. physicians.

Teaching ethics is crucial to health sciences education. Doing it well requires a willingness to engage contentious social issues. Those issues introduce conflict and risk, but avoiding them ignores moral diversity and renders the work of ethics education irrelevant. Therefore, when (not if) contentious issues and moral differences arise, they must be acknowledged and can be addressed with humility, collegiality, and openness to support learning. Faculty must risk moments when not everyone will “feel safe,” so the candor implied in psychological safety can emerge. The deliberative and social work of ethics education involves generous listening, wading into difference, and wondering together if our beliefs and arguments are as sound as we once thought. By forecasting the need for candid engagement with contentious issues and moral difference, establishing ground rules , and bolstering due process structures for faculty and students, a riskier and more relevant ethics pedagogy can emerge. Doing so will prepare everyone for the moral diversity they can expect in our common life and in practice.

Objective: Explore the roles of humility in healthcare delivery from perspectives of active doctors and nurses. Background: Although the concept of humility has gained attention in the healthcare and health professions education fields, previous literature has primarily been anecdotal reflections or conceptual explorations, leaving a gap of empirical approaches to what humility "looks like" in healthcare. Methods: Three hundred and five active U.S.-based doctors and nurses completed a survey containing close- and open-ended questions examining their experiences with and perceptions of humility in the clinical care setting. Results: The findings from this study echo previous literature touting the value of humility in regard to patient care, but also spotlight the connections between humility and status, how humility acts as a leveling mechanism, and humility's roles regarding facilitating collaborative, team-based care. We also find evidence of the effects of intellectual humility, as well as the tenets of the professional humility concept. Conclusion: According to doctors and nurses, humility is essential to high quality team-based, patient-centered care, but there is an explicit connection between humility and status - specifically related to the occupational status embedded within healthcare delivery. Future research should investigate not only how humility may facilitate interprofessionalism, but also the roles and impact of humility regarding uncertainty, and the processes related to feedback and decision making.

Introduction: Medical training traditionally holds a deterministic view of professional socialization wherein many medical learners struggle to construct a professional identity. Previous research has demonstrated the dysfunctional norms and conflicting ideologies that create identity struggle, disproportionally affecting women and individuals underrepresented in medicine. Symbolic interactionism can help explain identity struggles, emphasizing the influence of socio-contextual factors on identity construction. The purpose of this study was to explore how residents navigate identity struggles during residency training. Method: We conducted a qualitative exploration of 12 residents in three specialties at three academic institutions in the United States. Participants engaged in rich picture drawings followed by one-on-one interviews. We coded transcript data and met regularly to identify themes related to residents’ experiences with navigating professional identity struggles. Results: We identified three main themes on navigating identity struggles: the weight of identity work, the isolating nature of identity work, and the navigation that occurs with and against socio-contextual currents. Residents described identity work as navigation like a boat at sea. This work felt weighty and at times overwhelming and residents often felt unable to discuss their identity struggles with others. Residents utilized what agency they had to either navigate with the current, navigating towards acceptable—albeit imperfect—paths forward, or attempting to go against the current to forge new paths through resistance. Discussion: This study highlights how context enables and constrains identity construction, how contextual constraints can create dissonance between identities, and the considerable effort required to reconcile dissonance and construct professional identities. Training program adjustments, enhanced resident support, and cultural shifts are required to sustain residents’ identity work. Medical professionals should engage in collective identity work to reimagine the profession’s identity by addressing dysfunctional cultural norms.

INTRODUCTION:To enter a profession is to take on a new identity. Professional identity formation can be difficult, with medical learners struggling to adopt professional norms. The role of ideology in medical socialisation may offer insight into these tensions experienced by medical learners. Ideology is the system of ideas and representations that dominates the minds of individuals or social groups and calls individuals into certain ways of being and acting in the world. In this study, we use the concept of ideology to explore residents' experiences with identity struggle during residency. METHODS:We conducted a qualitative exploration of residents in three specialties at three academic institutions in the United States. Participants engaged in a 1.5-hour session involving a rich picture drawing and one-on-one interview. Interview transcripts were coded and analysed iteratively, with developing themes compared concurrently to newly collected data. We met regularly to develop a theoretical framework to explain findings. RESULTS:We identified three ways that ideology contributed to residents' identity struggle. First was the intensity of work and perceived expectations of perfectionism. Second were tensions between the developing professional identity and pre-existing personal identities. Many residents perceived messages regarding the subjugation of personal identities, including the feeling that being more than physicians was impossible. Third were instances where the imagined professional identity clashed with the reality of medical practice. Many residents described how their ideals misaligned with normative professional ideals, constraining their ability to align their practice and ideals. CONCLUSION:This study uncovers an ideology that shapes residents' developing professional identity-an ideology that creates struggle as it calls them in impossible, competing or even contradictory ways. As we uncover the hidden ideology of medicine, learners, educators and institutions can play a meaningful role in supporting identity development in medical learners through dismantling and rebuilding its damaging elements.

Medical-school applicants learn from many sources that they must stand out to fit in. Many construct self-presentations intended to appeal to medical-school admissions committees from the raw materials of work and volunteer experiences, in order to demonstrate that they will succeed in a demanding profession to which access is tightly controlled. Borrowing from the field of architecture the lens of construction ecology, which considers buildings in relation to the global effects of the resources required for their construction, we reframe medical-school admissions as a social phenomenon that has far-reaching harmful unintended consequences, not just for medicine but for the broader world. Illustrating with discussion of three common pathways to experiences that applicants widely believe will help them gain admission, we describe how the construction ecology of medical school admissions can recast privilege as merit, reinforce colonizing narratives, and lead to exploitation of people who are already disadvantaged.

Purpose Professional identity formation (PIF) is a dynamic process by which an individual internalizes the core values and beliefs of a specific profession. Within medical education, PIF begins in medical school and continues throughout training and practice. Transitions affect PIF, with a critical transition occurring between medical training and unsupervised practice. This study aims to characterize PIF during the transition from resident to early-career faculty physician and explores the relationship between PIF and burnout during this transition. Method The authors conducted a qualitative study using constructivist grounded theory. They conducted semistructured interviews with early-career faculty physicians (defined as practicing for ≤ 5 years) from the Department of Medicine, Mayo Clinic. Deidentified interview transcripts were processed through open and axial coding. The authors organized themes and identified relationships between themes that were refined through discussion and constant comparison with newly collected data. During data analysis, the authors identified self-determination theory, with the concepts of autonomy, competence, and relatedness, as a framework to support the organization and analysis of the data. Results Eleven early-career faculty physicians participated in the interviews. Their PIF was characterized by the dual desires to fit in and stand out. Striving for these desires was characterized by imposter syndrome, driving physicians to question their decision making and overall competence. Participants associated imposter syndrome and academic pressures with burnout. Autonomy support by the institution to pursue opportunities important for career development helped mitigate burnout and support PIF. Conclusions Early-career faculty physicians face identity challenges when transitioning from training to unsupervised practice, including striving to fit in and stand out. They link this tension to imposter syndrome, which they associated with burnout. Institutional awareness and support, including addressing structural and cultural contributors to imposter syndrome, are paramount as new faculty explore their identities and navigate new challenges.

Impostor phenomenon has gained increasing attention within the health care and health professions education literature. Although consistently depicted as a debilitating socioemotional experience, studies also suggest a strategic aspect to impostor phenomenon - denoting a conceptual ambiguity to impostor phenomenon that has yet to fully examined. Within this paper, we use humility as a conceptual sparring partner with impostor phenomenon to examine the similarities and differences between the concepts, as well as explore the various nuances associated with impostor phenomenon. By comparing and contrasting impostor phenomenon and humility from interdisciplinary perspectives and within the context of health professions specifically, we not only further refine their meaning and usage within the literature, but also spotlight key areas for future research.

The proliferation of education programmes goes some way towards professionalising teaching, but we mustn't let them devalue teaching by bypassing socialisation processes and professional identity formation.

‘Future proofing’ medical education requires a future-focused, advocacy infused, context sensitive and grounded in a reconceptualization of what it means to train physicians as ‘future professionals’. In considering these challenges, we must reimagine how we, as a community, wrestle with a fundamental issue facing medicine as a profession—medicine's future as a profession—including how to best re-engineer and recalibrate the work of education as a practice of professional preparation in service to this fragile yet critically important social status. Over the past quarter century, the emergence of a professionalism movement within medicine has generated a plethora of definitions, metrics, codes, charters, competencies and curricula intended to imbue professionalism—whether that be framed as a virtue, a behaviour or as an identity.1 More recently, programmes2 have been deployed to remediate professionalism shortcomings for what the culture of medicine insists are its ‘one or two bad apples’ and with a parallel focus—be that trainees, faculty or practitioners—on the individual. Even calls to address system factors typically frame those constellational elements in terms of their impact on the individual. One consequence of this rapidly institutionalised view of professionalism has been to routinely—even ritualistically—conceptualise ‘new professionalism issues’, professional identity formation being one example, as a property of individual social actors with little or no recognition that identity also is a collective issue, and thus medicine's own identity and its future as a profession should be being worthy of both our time and our imaginations. This lacuna also contains a small measure of irony since early calls within both within sociology3 and medicine4 largely focused on threats to medicine writ large than individual members. The problem with such a truncated focus is that it ignores both the complexities of professionalism5 as well as the complexities of a rapidly evolving health care system within which both professional preparation takes place and within which medicine must function as a profession. Today's health care contains an ever-expanding bevy of new health occupations along with new ways of paying for and organising medical work. Even billion-dollar companies (e.g., Google and Amazon) not traditionally seen as having a health care profile are now aggressively pivoting into the health care marketplace. Insurers (as payers) have acquired health delivery systems, with new systems spawning new residency programmes and medical schools—and with all players having their own vested interests—and accompanying visions—of what it means to practice medicine and in what or whose interests. Training programmes, whatever the level (undergraduate/UME, graduate/GME and continuing/CPD), need to recognise these complexities as they prepare future physicians—as professionals—to act both on behalf of patients, but also on behalf of their profession—as a profession. Among other things, this means that medical schools and residency programmes must re-imagine themselves not just sites of professional preparation (e.g., places where professionalism is taught and enacted), but as organisational entities that themselves express and embody professionalism as they engage in the work of preparing future professionals.6 In short, medical schools need to see professionalism as being reflected in the way they organise the work of delivering medical education. All of which brings us to a more genuinely systems view of professionalism as we begin to imagine the expression of professionalism as extending beyond the individual to the various constituencies that make up the House of Medicine, including its various membership groups (specialty based and otherwise) and thus how these entities act and interact as expressions of professionalism. Whatever the particulars, when we talk about professionalism we are talking about the fundamental logic of professionalism—with logic ‘… a socially constructed, historically developed pattern of beliefs and rules that shape the organising principles of an institution …’7 and professionalism a way or organising work in contrast to the logics of the market and of bureaucratic managerialism.3 This also means what when we practice and teach professionalism, we do so by explicitly ad strategically recognising the presence of countervailing logics within the practice of both medicine and professional preparation.8 In addition, we need to be mindful of potential differences between stated purpose versus the purpose-in-action and thus the presence of a hidden curriculum within professional preparation—a restructuring that prepares both training environments and its inhabitants to both advance the public service mission of the profession as well as to recognise and resist countervailing logics. Not to do so raises the potential for medicine to suffer from identity expropriation/degradation as other logics, such as those of the market and managerialism continue to infiltrate and replace key elements in how health care professionals themselves organise and make sense of their work. Medical education has not been cognizant enough of this theft/infiltration/expropriation and as such needs to be more proactively strategic in helping the next generation of physicians recognise and counter the presence of these often invisible and countervailing forces in how they are reshaping the structure and practice of medical work—all of which constitute a particular threat where a compliance follow-the-rules version of what it means to be a professional blurs the potential of both members and the profession to critical examine ‘whose rules’ and thus to better understand ‘to what end and benefit’ these rules might operate. Ultimately, ‘to future proof’ both medical education and professional preparation means to thus ensure an educational system that speaks to the service of medicine as a profession—which means attending to professionalism as something more than just an individual-level phenomenon. Otherwise, we may usher in an era in which we educate future practitioners rather than future professionals.9

The college-level pathway to medical school (i.e., the "premed path") includes all coursework, extra-curriculars, shadowing, volunteering, high-stakes examination (e.g., MCAT®), and application-related processes. Although medical school admission committees routinely insist their interest in diverse and "well-rounded" applicants, the premed path (PMP), through formal and informal mechanisms, is constructed to favor those from high in socioeconomic status (SES) privileged backgrounds, and those majoring in typical premed majors such as in the Biological Sciences. In these respects, the PMP is an example of Discriminatory Design-an entity constructed and sustained in a manner that (un)intentionally discriminates against certain groups of individuals. We begin this paper by providing a brief description of the PMP (within the U.S. specifically) and conceptual and theoretical overview of the discriminatory design framework. We then explore how the PMP is an example of discriminatory design through the distinct but related role(s) of financial, social, cultural, and (what we term) (extra)curricular capital. Using data gleaned from interviews with premedical students, content analyses of the curricular structure of particular majors and publicly available data on the various "costs" associated with the PMP, we detail how the PMP is reflective of discriminatory design, spotlighting specific barriers and hurdles for certain groups of students. Given the persistent lack of representation of students from minoritized groups as well as those from diverse academic backgrounds within medical schools, our goal is to spotlight key features and processes within the PMP that actively favor the pursuit of certain majors and students from more privileged backgrounds. In turn, we conclude by offering medical schools and undergraduate institutions specific recommendations for remediating these barriers and hurdles.

Introduction Professional identity formation (PIF) is the internalization of characteristics, values, and norms of the medical profession. An individual's identity formation has both psychological and sociological influences. Social psychology may be useful to explore the interactions between the psychological and sociological aspects of PIF. In this study, we explored how resident physicians navigated tensions between professional ideals and the reality of medical practice to characterize PIF during residency training. Methods Using constructivist grounded theory, the authors conducted 23 semi-structured interviews with internal medicine residents. Interview transcripts were processed through open coding and analytic memo writing. During data gathering and analysis, the authors utilized Social Cognitive Theory, specifically the bidirectional influence between person, behavior, and context, to analyze relationships among themes. Theoretical insights were refined through group discussion and constant comparison with newly collected data. Results Residents described tensions experienced during residency between pre-existing ideals of "a good doctor" and the realities of medical practice, often challenging residents to reframe their ideals. The authors provide evidence for the presence of dynamic, bidirectional influences between identity (person), behavior, and environment (context), and demonstrate how PIF is informed by a complex interplay between these elements. The authors present two examples to demonstrate how residents reframed their ideals during residency training. Discussion The complex bidirectional influences between person, behavior, and context, informed by SCT, helps illuminate the process of PIF in residency training. This study highlights the effects of the context of residency training on the development of residents' professional identities.