Changing the Conversation: Assessing the Hidden Curriculum of Medical Student Education and Improving the Care of Patients With Limited English Proficiency Through Resident Training

Abstract

Purpose: Patients with limited English proficiency (LEP) are a growing population and are at increased risk for lower quality and safety of care due in part to communication barriers. Formal medical education usually emphasizes the importance of ensuring optimal communication with patients with LEP using interpreter services. Medical student learning and clinical practice, however, is heavily influenced by a hidden curriculum including the attitudes transmitted by superiors and the learning environment in hospitals. In this study, we aimed to improve the hidden curriculum through systems interventions that target the people most directly involved in clinical education of medical students; the residents. Given that assessment tool yet exists to measure this hidden curriculum, we first created and validated an assessment instrument to evaluate the current hidden curriculum prior to the implementation of our interventions. Method: Based on the findings from previous qualitative work, input from medical students and experts in LEP and psychometrics, we developed a 23-item survey. We emailed this survey to third and fourth-year students at two large U.S. medical schools and conducted principal axis factoring on the response to determine the instrument’s construct validity. Based on the factor extraction solution, we retained items with a factor loading of 0.50 or greater and restructured the instrument to create our final validated instrument that can be used to measure the hidden curriculum and to monitor changes caused by interventions. We subsequently implemented a set of system-based interventions aimed at increasing resident awareness and training as well as improving coordination of care with interpreter services. This was done at two sites. We surveyed students 3 months and 6 months after the initial intervention at the various sites to assess if the curriculum had changed. We compared the pre- and post-intervention mean scores for the control and intervention groups, respectively, using an independent Student t-test Results: Instrument construction and validation: We obtained 111 complete responses. Twenty-two of the 23 original items were retained. Four factors/components emerged, which did not support the original proposed domains. Three factors loaded on a mix of role modeling, learning environment, structural, and organizational variables, while the fourth factor retained two role modeling items. Based on the factor extraction solution we restructured the instrument into three domains: role modeling, demonstration of effective systems, and consequences of structural barriers for patients with LEP (Cronbach’s alpha: 0.81 – 0.95, total variance accounted for: 53.7%). Intervention implementation: Obtained 72 complete responses. We saw small to medium sized changes in students’ perception of the hidden curriculum between the pre and post intervention groups in all four domains. Changes were not statistically significant. Conclusion: The results of our instrument validation led us to reassess the domain structure to create an instrument representing students’ perceptions and context. We used our LEP-HC instrument to evaluate the impact of our intervention on the hidden curriculum and students’ experience learning to care for patients with LEP. Although we did successfully improve access and education about the care of Patients with LEP in the selected departments, we did not see statically significant or profound changes in medical students’ perceptions of the hidden curriculum following interventions. This might be due to our relatively small sample size. This study may need to be repeated with a larger sample size to gauge utility of these interventions. Our LEP-HC instrument will allow medical educators to investigate a specific and important hidden curriculum and improve students’ experience learning to care for patients with LEP.