The Hidden Curriculum: Implicit Hierarchies in the Interprofessional Clinical Learning Environments

In traditional clinical learning environments (CLEs), providers work alongside one another with noted power differentials. The Boston University Community Health Alliance of Medical Professionals (BU CHAMPs) equips the next generation of providers with core interprofessional skills including communication, roles and responsibilities, and teamwork to address siloed clinical training and reduce health disparities for underserved populations experiencing chronic disease and social stressors. With funding from Health Resources and Services Administration (HRSA T0BHP30021), BU CHAMPs facilitates interprofessional experiential learning among medical, physician assistant, nutrition, and social work trainees.

In individual interviews and team-based focus groups, trainees identified learning strategies and structural elements conducive to a collaborative and patient-centered Interprofessional Care Clinic (ICC). Learning strategies included peer modeling, use of a case-based curriculum, and simulated patient interactions with standardized patients. Trainees noted the importance of team huddles, consultation with an IP preceptor team, and debrief of clinical experience.

Unidisciplinary trainee and preceptor focus groups highlighted the existence of a medical-centric hierarchy within the hidden curriculum. Preceptors often identified the medical professional as lead based on responsibilities, including primarily facilitating the curriculum and clinical care session. Trainees perceived clinic structure and preceptor team dynamics contributing to a traditional culture. In response to this feedback, BU CHAMPs conducted preceptor team development training sessions, shared facilitation of curriculum among all discipline leaders, empowered all trainees to take leadership roles, and offered transparency regarding medical-centered clinical operations in a community health center. In follow-up unidisciplinary focus groups, trainees reported feeling valued by members of their team, and noted the shared leadership, trust, and appreciation between the IP preceptor team.

Through qualitative findings and implementation of quality improvement efforts, the BU CHAMPs program elicited open conversation about the culture in an IP CLE. Addressing implicit hierarchies allowed for psychological safety and confidence among preceptor and trainee teams.