Original Articles

Journal of General Internal Medicine

, Volume 18, Issue 12, pp 1015-1022

First online:

The disavowed curriculum

Understanding students’ reasoning in professionally challenging situations
  • Shiphra GinsburgAffiliated withReceived from the Department of Medicine, Faculty of Medicine, Center for Research in Education, University of Toronto Email author 
  • , Glenn RegehrAffiliated withDepartment of Surgery, Faculty of Medicine, Center for Research in Education, University of Toronto
  • , Lorelei LingardAffiliated withDepartment of Pediatrics, Faculty of Medicine, Center for Research in Education, University of Toronto

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CONTEXT: Understanding students’ perceptions of and responses to lapses in professionalism is important to shaping students’ professional development.

OBJECTIVE: Utilize realistic, standardized professional dilemmas to obtain insight into students’ reasoning and motivations in “real time.”

DESIGN: Qualitative study using 5 videotaped scenarios (each depicting a student placed in a situation which requires action in response to a professional dilemma) and individual interviews, in which students were questioned about what they would do next and why.

SETTING: University of Toronto.

PARTICIPANTS: Eighteen fourth-year medical students; participation voluntary and anonymous.

MAIN OUTCOME MEASURE: A model to explain students’ reasoning in the face of professional dilemmas.

RESULTS: Grounded theory analysis of interview transcripts revealed that students were motivated to consider specific actions by referencing a Principle (an abstract or idealized concept), an Affect (a feeling or emotion), or an Implication (a potential consequence of suggested actions). Principles were classified as “avowed” as ideals of four profession (e.g., honesty or disclosure), or “unavowed” (unacknowledged or undeclared, e.g., obedience or allegiance). Implications could also be avowed (e.g., concerning patients) or unavowed (e.g., concerning others); but students were predominantly motivated by considering “disavowed” implications: those pertaining to themselves (e.g., concern for grades, evaluations, or reputation), which are actively denied by the profession and discouraged as being inconsistent with altruism.

CONCLUSIONS: This “disavowed curriculum” has implications for education, feedback, and evaluation. Instead of denying their existence, we should teach students how to negotiate and balance these unavowed and disavowed implications and principles, in order to help them develop their own professional stance.

Key words

undergraduate education medical education professionalism evaluation