VOLUME 33, ISSUE 2

Anesthesiology residents acquire a set of skills as part of a curriculum which involves didactics and clinical training. The term “hard skills” has been used to describe specific, well-defined, teachable abilities that are not interpersonal but are required for a specific role. Competency in these hard skill areas can typically be subjectively and objectively measured. Some examples of hard skills in the context of anesthesiology practice are airway management, vascular line placement, knowledge of pharmacodynamics and pharmacokinetics of commonly used anesthetic agents, and the quick decision making needed during management of critically ill patients. These qualities are necessary, easily observed, appreciated by all, and are critical for career success. Patient care and medical knowledge are the Accreditation Council for Graduate Medical Education (ACGME) core competencies that fall under this category.

Conversely, the term “soft skills” is used to describe behavioral and interpersonal skills that help an individual function well in a team setting. Working as part of a team is a quintessential requirement in our daily work routine. Soft skills are typically less tangible and more difficult to quantify or teach. Systems-based learning and improvement, professionalism, interpersonal skills, and communication make up 4 of the 6 ACGME core competencies and are categorized under soft skills. A resident is expected to demonstrate increasing proficiency in both hard and soft skills during their training. Historically, there has been a distinct lack of a defined curriculum to teach these competencies. Without a defined curriculum, residents learn soft skills by observing faculty in daily scenarios. These skills become accepted as the culture of a training program. Consequently, anesthesiology residents might continue to follow certain undesirable behaviors in their careers long after finishing residency. This process has been termed “hidden curriculum” and, for good or bad, can shape the future of the next generation of physicians.

Hidden curriculum in medicine refers to the implicit teaching that occurs outside of the formal curriculum of lectures and clinical education. It consists of values, behavior, and attitudes that are deeply rooted in the departmental and organizational culture. Professionalism is one such competency learned by the residents implicitly via actions of the members on their team. Residents learn from observing the consequences or lack of consequences for the actions or inactions of those around them.

Anesthesiologists, as peri-operative leaders, need to be proficient at communication and coordination of services, while being adaptable to changes that occur in real-time. How can our residency programs help groom our residents into better leaders? These are certainly unprecedented times for our specialty with changes in the way we practice and emerging nuances in the way a new generation of learners learn.

It is undisputed that professionalism is an essential soft skill that needs to be taught to medical students and residents early on in their careers. A study from 2004 demonstrated that medical students who demonstrated unprofessional behavior were more than twice as likely to be disciplined by the medical board1. A lapse in professional behavior is often easily identified. However, there are often gray areas and no clear definition of the attributes of a physician anesthesiologist who exhibits professionalism. Anesthesiology residents learn from their senior residents, fellows, and faculty in various scenarios. The vast majority of this learning happens in locations other than the ‘formal classroom’. For example, by observing seniors and faculty around them, residents learn how to conduct themselves in the operating room, how to manage a difficult patient in the recovery room, and learn how to communicate with the patient and the perioperative team after an error was made. Whether the faculty member realizes it or not, they are continuously teaching with their behavior and actions and the residents are continuously learning. Academic faculty should, therefore, be mindful of this tacit teaching and always behave in a way that will guide residents towards being more professional physicians and citizens in their community.

With respect to professionalism, mimicking the actions of academic faculty alone might not be enough to instill professional behavior in residents in today’s rapidly changing work dynamics2. Often, academic faculty themselves don’t have a clear idea of how best to teach professionalism to their residents. Residency programs also have no clear guidelines about how to assess residents for professionalism. Therefore, clear definitions of attributes constituting ideal professional behavior in different contexts of clinical practice are essential. Perhaps, it is also time to teach professionalism to the faculty explicitly via a structured curriculum3.

Steinart et. al. propose a stepwise approach to faculty development for teaching and evaluating professionalism3. They propose starting with a brainstorming session to stress the importance these skills and to then develop consensus and outline a plan for a teaching structure in order to obtain buy-in from all of the faculty members as well as the other members of the organization. They recommend following this with a workshop for a small cohort of faculty where the faculty can test the working definitions of the attributes of professionalism and then examine the strengths and weaknesses of the diverse teaching methods proposed. Feedback on the on all these issues can then be collected to guide further actions. Based on this feedback, they recommend expanding the program to all faculty and re-evaluating these teaching methods frequently. It is also recommended that such a curriculum have dedicated time of reflective thinking for faculty3,4. Development of a better understanding of what constitutes professionalism will help clarify the behaviors that the faculty should model for the residents as they learn these soft skills. These newly defined attributes might also make it more straightforward for the residency program leaders to assess professionalism and the other soft skill core competencies among their resident cohort.

Barriers to implementing such a faculty-based professionalism curriculum may be lack of buy-in from the leadership and faculty as well as the time constraints for developing and attending the course by faculty who have increasing clinical demands.3 Once these attributes are defined for a department, these cultural ‘norms’ should then be frequently re-assessed to determine if updates or changes are needed.

The ability to develop such a curriculum requires the support of the institutional and departmental leadership in order to increase the chances that it will be embraced by faculty members. These changes have the opportunity to effect positive change in departments and entire health systems as culture shifts occur. These changes would likely create a positive shift in how our young physicians develop these attributes of professionalism.

As physician anesthesiologists and perioperative leaders, we need to unveil the hidden curriculum and openly discuss and teach professionalism to all individuals of the perioperative team. Our active role in developing educational strategies to teach professionalism in our programs will help develop future healthcare leaders.