Nathalie Feldman, M.D. and Abigail Belser
Nathalie Feldman, M.D., and Abigail Belser '22

Uncovering the Hidden Curriculum

Medical schools revolve around curricula, syllabi and course objectives—all designed to make sure future doctors have extensive knowledge of the human body and the clinical skills to diagnose and treat patients. But there’s also the underlying lessons students absorb, ones that aren’t necessarily overt: the hidden curriculum. Feldman describes this as an “acculturation,” based in part on the subtle messages sent via the behavior of faculty and trainees.

Since it’s largely unspoken, the hidden curriculum can have an outsized impact. Students are less inclined to question what they’re learning, even if the dynamics they observe are unhealthy. For example, if a student sees a physician treating a nurse or a resident with disrespect, they may internalize the example being set. They may “question whether they belong,” says Feldman, or decide that they just “need to toughen up.” Feldman and colleagues across the College, including the Office of Diversity and Inclusion and the Learning Environment and Professionalism Committee (LEAP), want to create the space for students to talk about what they’re witnessing— the good and the bad.

“The learning environment efforts are really about dialogue across divides, whatever the divides might be,” she says. A new, confidential, online reporting system streamlines how students communicate about learner mistreatment and offers various options for intervention, from anonymously reporting a concern, to meeting with Feldman or another faculty member to decide how to proceed, to, in the most serious cases, filing a report of harassment or discrimination directly with UVM’s Affirmative Action and Equal Opportunity Office. It’s important that the available options be easily accessible and as transparent as possible, Feldman says, so that students know where and how they can receive support.

The online system also includes a call for accolades. Students can write in praise for individuals who have “upheld the highest standards of professionalism.” Testimonials are shared anonymously with the recipient and their direct supervisor.

In addition, students reflect on professionalism through two new questions on course and clerkship evaluations. One offers students an opportunity to identify faculty members, residents or staff who are “exemplars of professionalism.” Feldman says the response rate continues to astound her—the large number of accolades is a testament to the impact of these positive role models on students.

The second new question asks students to address any instances of potential mistreatment or unprofessional behavior they may have witnessed or experienced. Students explore how they perceived the action and receive support if desired. Through this system, trends and themes can be identified, empowering the College to provide education and professional development to improve the learning environment.

“Giving voice to our students provides an opportunity for them to engage in the process of improvement,” says Feldman.

Ongoing research seeks to quantify the effect of the College’s emphasis on reflection and gratitude, with Abigail Belser ’22 at the front lines of this work. She spent the summer of 2019 as the learning environment intern, leading a study to measure the impact of the new accolade reporting system. She found strong student participation: Of the 851 clerkship evaluations received in the 2018-19 academic year, 67 percent contained one or more accolades. Belser and co-investigators analyzed themes in what students wrote and collected responses from faculty who received accolades.

“Just adding this simple question to the course evaluations actually has a positive impact on a lot of people, which I think is pretty exciting,” she says.

The study, which was presented at the 2019 Association of American Medical Colleges (AAMC) annual meeting, invites further research. Leigh Ann Holterman, Ph.D., director of curricular evaluation and assessment and a co-investigator on the project, says the next step will be looking at the accolade reporting system’s effect on burnout. Structured interviews with faculty and students should help dig deeper into how encouraging gratitude changes the status quo.

“We want to see what impact it has on students,” says Holterman. “Does it change anything for them that they can identify? Then for the faculty, does it impact their desire to teach? Does it allow them to feel more invested?”

Belser is hopeful her peers will benefit from identifying role models early in their education, setting them up for a lifelong focus on positive change.

“Many studies have shown that gratitude—either taking a minute yourself to be grateful or also receiving thanks and appreciation—can have protective effects against burnout,” she says. “So, we think potentially doing something as simple as asking students to write a positive review about a faculty member could be beneficial to both students and faculty.”


“It’s about all of us being the best we can be and acknowledging empathy and compassion when we witness it. If we elevate the positive, it will begin to dominate our experience.” - Nathalie Feldman, M.D.

Bridging the Divide

At least four generations—from the Baby Boomers to Generation Z—now work in the field of medicine, bringing with them a cornucopia of communication styles, work styles and expectations for others. And although there’s still much work to be done, trainees are the “most diverse, culturally and ethnically, that they have ever been,” says Feldman. In this environment, cultural humility—understanding the limits of your own perspective and being respectful of another person’s experience—is key. And fostering it requires connecting with others in meaningful ways.

One program aimed squarely at making space for honest exchange: Cup of Coffee Conversations, where community members have the opportunity to sit down with a trained peer to discuss a misunderstand- ing or miscommunication. The model, first developed at Vanderbilt University’s Center for Patient and Professional Advocacy to address unprofessional behavior in hospital settings, is being adapted by the LEAP Committee for use in medical education. Although Feldman is always available to confidentially discuss issues regarding mistreatment, the Cup of Coffee Conversation allows trained peers to come together to engage in dialogue to resolve an issue in a non-punitive way. The peer-mediated model gives the involved parties the “power to be the change agent,” Feldman says.

The pilot program recently expanded to include residents at UVM Medical Center, a novel innovation that the College plans to further explore, says Melissa Davidson, M.D., a member of the LEAP Committee and associate dean for graduate medical education at UVM Medical Center. Instead of channeling a report to their program director—a person responsible for formal evaluation—what could feel punitive is turned into a learning opportunity.

“To have that one conversation with somebody who is not part of the program feels different,” she says.

Written feedback—both from students to instructors and instructors to students— can be another realm fraught with misunderstanding. So when faculty and residents voiced concerns over the nature of some of the written comments they had received from students, and students expressed a desire to learn more about how their feedback is used, the LEAP Committee, in collaboration with students from the College’s Student Education Group (SEG), launched a session devoted to the topic. The students worked in small groups to craft constructive feedback. They also heard from individual faculty members about how students’ responses to their teaching impacts them and helps them to improve. Sidney Hilker ’21, vice chair of SEG, says students took the conversation to heart.“[Giving constructive feedback] is both a science and an art that you have to learn from practice,” Hilker says. “And I think that was a message well-received.”

Davidson, who hosts similar trainings for new residents and fellows at UVM Medical Center, helped to run the session for students.

“The outcomes were so positive that the students said that they wished they had gotten this earlier,” she says. “They recommended that we do it for incoming medical students right on day one.”

As a result, the workshop has now been incorporated into orientation for first- year students. For faculty, Feldman and colleagues have hosted sessions for the Teaching Academy’s Medical Education Grand Rounds, featuring time to workshop feedback and a student panel focused on how faculty feedback affects them.

Feldman and colleagues, including LEAP Committee member Judy Lewis, M.D., also seek to share insights with other institutions. A learning environment curriculum utilizing videos designed and created by Feldman, Lewis and colleagues has for several years been exporting the College’s approach to professionalism and the learning environment. The films—one focused on the experience of medical students and the other on faculty, staff and residents—depict instances of potential mistreatment. After viewing the films, audiences engage in facilitated dialogue around represented themes, with the goal of bridging generational, hierarchal or interprofessional divides. The curriculum, published on Med Ed Portal, has been integrated into the third-year clerkship orientation as well as the residency orientation at UVM Medical Center. Institutions including Yale University, Columbia University and the Mayo Clinic have adopted these materials for GME orientation and faculty development series. Presentations at national conferences including the International Association of Medical Educators Annual Meeting have sparked interest in medical schools around the globe.

“Film has a unique ability to elicit empathy,” says Feldman. “It brings up great discussions.”

Yoga Student Interest Group

The Yoga Student Interest Group hosts a session for students on the Larner College of Medicine campus.

Lifelong Wellness

The first step for a physician seeking to provide high quality patient care may seem simple: “They need to be fully present,” says Lee Rosen, Ph.D., assistant professor of psychiatry and director of student well- being. Turns out modern medicine poses some challenge for this most important task.

“There’s the difficulty of engaging with people who are suffering,” says Rosen. “And then there’s doing it in this health care environment which has features that can be very mechanistic, that can draw people’s attention away from the most meaningful parts of their work. We have to give students the tools to be prepared for that.”

Just like building clinical skills, fostering emotional health requires “explicit curriculum,” one that is intertwined with the LEAP Committee’s work on professional identity formation and the College’s infrastructure for academic support.

“When you go to yoga, when you sleep, when you engage in meditative practice, you’re consolidating knowledge,” Rosen says. “You’re taking care of your brain.”

The student-run Wellness Committee offers a plethora of activities, from one-on-one peer support to spring and summer creemee nights. Their twice annual mental health panel, which features students speaking to their peers about their experiences accessing mental health treatment, is destigmatizing the process of asking for help. The Yoga Student Interest Group hosts free, weekly sessions on campus. A new meditation guide, created by Rosen and Collin York ’20 is available on the College’s website. And mindfulness has been integrated into the curriculum; several courses feature pre- exam mindfulness sessions in the classroom. A biannual survey from the Wellness Committee offers opportunities to check in with the student body and improve offerings.

A Student Well-being Research Group meets regularly to look at outcomes related to wellness and share knowledge with other medical schools. In 2019, Rosen and Holterman presented a poster on the student mental health panel at the AAMC’s Northeast Group on Educational Affairs annual meeting that was nominated for an Excellence in Medical Education Award. And although it’s in the early stages, the group is working on a well-being index that would quantify student rates of depression, anxiety, stress, and other markers of wellness over time.

Ultimately, the goal is to bring intention and focus to the question: “What kind of doctor do I want to be?” As she begins her life as a physician, Sidney Hilker ’21 sees benefit in naming the challenge.

“I think it’s a new frame to say, ‘How do I become exceptionally professional or known for my professionalism?’ she says. “I have a definition for what that means to me. I think it’s a little different for every person, whether it’s about being a team member everyone wants to work with, or someone who’s excel- lent at giving feedback and people look to for feedback, or people look to as a mentor.”

It’s okay to ask the question over and over again, says Feldman. “This is a process, an evolution—a lifelong journey.”

Story by Erin Post
Photography by David Seaver

Web Extras

Visit Med Ed Portal to see the professionalism learning modules created by a team of Larner College of Medicine faculty and students: