Any guesses at who I’m describing? 

Well if you guessed Where’s Waldo, you’d be right!  Waldo – or Wally for any UK readers – has been frustrating children and adults alike since 1987.  You know he’s always there amongst the crowd of numerous characters doing their thing.  And sometimes you find him right away but other times you start to convince yourself that he really isn’t there & that maybe the author is playing a trick on you or just forgot to draw him into this one. But after you step away for a moment to breathe, you come back to find him plain as day staring back at you.  And in your shock you wonder, “how did I miss him before?  I literally looked at this part of the picture like twenty times!”  But you know, I think medical education has its own Waldo, namely moral formation in the “hidden curriculum” which is waiting for us to find him.  

Within the context of residency, medical moral formation occurs during the socialization of acquiring our professional identity.  And by medical moral formation I mean the messages we receive to be good/bad, right/wrong, appropriate/inappropriate within the context of medicine.  Frederic Hafferty and colleagues described the process as a schematic you can imagine with 3 squares side-by-side.  On the left is your existing identity prior to medical education and on the right is your professional identity as a medical student, resident, and physician.  In the middle is the socialization that your embodied self must encounter.  This process has multiple inputs including experiences, role models/mentors, the learning environment, peers, family, patients, and formal teaching that are all encountered and sometimes acquired unconsciously.  But when your existing identity is dissonant to this experience the learner will either compromise or negotiate who they are in light of these experiences.  

One thing we should notice is that formal teaching is only one of many inputs during our identity formation in medical education.  I would argue that even our experiences during formal teaching – I’m thinking especially of medical student/resident led teaching – has greater formation based on how upper-levels and attendings respond to certain topics or presenters, what questions are asked, or how someone is interrupted to make a correction, rather than the actual content of the teaching.

Nevertheless, how a physician discusses or responds to certain topics, how & what about we joke, and how we talk about patients away from earshot is just a short list of obvious contents of the hidden curriculum.  And as the schematic shows our individual, unique embodied selves must encounter this within the social process.  But the problem is each individual is left to analyze, compromise and negotiate aspects of their identity on their own without an accessible  standard from the institution of medical education with which to compare it.  It’s like we’re trying to find Waldo but without a complete picture of what he looks like.  Some people may find him eventually but without the picture of Waldo on the cover they would not be confident that they actually found him.  Better yet, someone else might claim a dog is Waldo because it’s wearing a red and white striped sweater with glasses and a bobble hat.  And without knowledge of who Waldo is, there would be no way to prove that the dapper dog is actually Waldo’s dog Woof and not Waldo himself.

We all want to be good physicians, but a consequence of divergent conceptions of a good physician is vulnerable residents slowly compromising aspects of their identity toward decisions & behaviors that are antithetical to the patient’s good.  Without an accessible standard of the good physician, the same experience could yield multiple takeaways by multiple residents.  For example, a bad physician operating out of vice could influence resident moral formation to the detriment of a vulnerable resident.  Therefore, residents need to be equipped to analyze whether encounters & experiences in residency are forming them into or malforming them away from becoming a good physician.