In our initial search, 1748 articles were identified (after duplicates had been removed) and included in the title and abstract review. After manually searching the reference lists of the articles included in the full-text review, 22 additional articles were added. In total, 29 articles met the inclusion criteria for Q1. The complementary searches, performed after analyzing data for Q1, generated in total 2130 articles (after duplicates had been removed), manual searching generated an additional 8 articles. Of these, 32 articles met the inclusion criteria for Q2. Reviewing the full texts resulted in the final numbers of 9 studies included for Q1 and 11 studies included for Q2. The articles were published between 2000 and 2019. Figure 1 and 2 display the article selection processes in PRISMA flow charts (24). Key features of the studies included are described in Additional files 5 and 6.
Elements of the informal curriculum applicable in a Family Medicine context (Q1)
The informal curriculum
The articles studied seemed unified in agreement on a significant existence of an informal curriculum in Family Medicine. However, definitions varied on what this meant. The informal curriculum is clearly defined in only one of the included articles, where it is juxtaposed to the formal curriculum as something that has not been “organized into a coherent whole […] written into curricular components” (25). The hidden curriculum is defined in three articles (26-28), with two of those referring to Hafferty’s established definition of “a set of influences that function at the level of organizational structure and culture” (26, 27) and one article using the following, more prosaic, definition: “a set of values students learn no matter what we decide to teach them” (28). Explicit definitions are lacking in five of the articles (29-33), but the terms are discussed in relation to interpersonal learning, and as in being a continuous influence reaching beyond medical school (29, 33). Moreover, related concepts such informal learning, opportunistic learning and ad hoc learning were found; sometimes they were also used interchangeably (30, 31).
Through the process of narrative synthesis three overall, and partly intersecting, elements constituting the informal curriculum of FM were developed: gaining cultural competence, achieving medical professionalism and dealing with uncertainty.
Gaining cultural competence
The first element - ‘gaining cultural competence’ - was derived from six of the articles included; there were two surveys, two qualitative studies, one review, and one opinion article dealing with this subject matter (25-28, 30, 31). Cultural competence is a broad and complex concept and in this review we have chosen to use the most commonly cited definition developed by Cross, et al: “Cultural and linguistic competence is a set of congruent behaviors, attitudes, and policies that come together in a system, agency, or among professionals that enables effective work in cross-cultural situations” (34). The concept of cultural humility is also worth mentioning. It is described as a closely related term, albeit, by some, as a separate concept (35). It incorporates “a lifelong commitment to self-evaluation and critique, to redressing the power imbalances in the physician-patient dynamic, and to developing mutually beneficial and non-paternalistic partnerships with communities on behalf of individuals and defined populations” (35). For the purpose of this review we have chosen to combine the two definitions under the same theme.
The gaining of cultural competence was, to a great extent, agreed to occur in an informal manner (25-27, 30, 31). A large survey of FM residency programs in the U.S. also confirmed that, in the majority of the programs included, cultural competence was identified as being part of the informal curriculum (25). Although experiential learning, through for example exposure to cultural diversity, was discussed as an important way of learning (25-27, 30, 31), the risks of ad hoc learning – having to rely on individual patient encounters as triggers for learning or being over-reliant on a supervisor’s knowledge and interest – were also discussed (27, 30, 31). A review concluded that a best practice method of ensuring cultural competency training has not yet been established (30). However, formal education is more likely to improve cultural competency than merely being exposed to culturally diverse patients, even when having access to good role models (30).
Achieving medical professionalism
The second element – ‘medical professionalism’ – is also a complex and broad concept varying over time and within cultural contexts, and can be assessed on several levels: individual, inter-personal, and societal-institutional (36). Professionalism is not only closely associated with a higher quality outcome of health care, but also with increased patient satisfaction, improving physician-patient relationships as well as with a higher career satisfaction (37-39). Four articles discussing this theme were included; one qualitative study and three opinion articles (28, 29, 33, 40). The included articles sorted under this term in our review mainly dealt with interpersonal aspects: the ability to engage with and establish a sound relationship with patients, working collaboratively with colleagues, and inter-professionally: avoiding reinforcing hierarchies (28, 29, 33, 40). Individual aspects such as the importance of self-awareness and reflection were also discussed (33, 40). Professionalism was discussed as being learned through role models as part of an informal curriculum, where acceptable professional behavior mainly was identified through observation (28, 33).
Dealing with uncertainty
The third element – ‘dealing with uncertainty’ – was derived from two of the articles included; one qualitative study and one opinion article (28, 33). Uncertainty is a concept with a variety of constructs, which is beyond the scope of this article to discuss in depth. However, in summary, it often refers to the diagnostic uncertainty inherent in the nature of the field of medicine and is a product of a combination of clinical judgement, information processing skills and biomedical knowledge (41-43). This also reflects what was discussed in the articles included in this review where dealing with uncertainty involved dealing with not knowing the answer, as well as dealing with situations when there is no correct answer (28, 44). It also involved dealing with uncertainty in terms of what could be considered “appropriate” behaviour and in relation to what should be discussed overtly with patients (33).
Educational interventions for Family Medicine residents, visualizing the various elements of the informal curriculum (Q2)
Design/data collection
Six quantitative studies (44-49) were identified for this review, out of which five described cultural competence interventions (45-49). Single group pre-post design was used in three of these studies (44, 48, 49); and one was non-comparative, with surveys administered after the intervention (47). One study compared the intervention group to a control group, although not randomized, since it involved participants who had applied for a certain program with focus on cultural competence (46). There was, however, one RCT (Randomized Control Trial) where data was gathered using a self-assessment tool designed to evaluate cultural competence (45). The most common method of data collection used was questionnaires constructed in alignment with learning outcomes of the respective intervention (45-47, 49). The study on uncertainty stood out in a positive way using four different scales with established psychometric properties measuring tolerance of uncertainty and ambiguity (44). One study also used patient ratings of behavior, as well as observations pre-post the intervention, with focus on cultural competence (48).
Two qualitative studies were also included (17, 50) both evaluating interventions aimed at increasing medical professionalism. Semi-structured interviews were used for collecting data, the analysis was performed using grounded theory (50) and a “modified analytic inductive approach” not explicated further (17).
One of the studies used mixed methods, where a qualitative analysis of reflective texts and photos taken by residents were combined with a questionnaire (51). Although a small study and thus difficult to draw any conclusions from, the innovative approach of using art as a tool for reflection was valued by the participants (51).
Two of the studies only briefly described their methods, which mainly seemed to involve discussions (52, 53).
Context and setting
Of the interventions included, six took place in the U.S. (44-46, 48, 50, 52), two in the U.K. (49, 51), two in Canada (17, 53), and one in Australia (47). The number of participants were reported for all the studies and ranged from 4 to 1467, with the mean number being 171 and the median 18.
There was an equal distribution between isolated workshops taking place within a short time frame (<3 months) ranging in number of occasions from 1-10 (45, 47, 49, 51-53), and the intervention being integrated long-term with various time intervals over the period of at least one year (17, 44, 46, 48, 50).
Various educational settings were used; small-group settings (47, 49-53) and a combination of clinical immersive settings with small-group and/or classroom settings (44, 46, 48) were the most common. One study used an internet-based setting for an interactive case-based course (45).
Intervention methods
A wide variety of teaching interventions were used, the most common being small-group discussions (46, 47, 49, 52, 53). One study also used Balint seminars (54) to teach professionalism (50). Explicit didactic teaching was less present (17, 46, 48). Only one study explicitly mentioned mentorship (17). Notably, there were also several creative and maybe less traditional methods used, such as reflecting on clips from the TV-show “Grey’s Anatomy” to improve professional behavior (52), using photography as a means to self-reflection (51), and discussing poetry in order to gain insight into other cultures (47).
Expected learning outcomes
Expected learning outcomes were in most of the studies mentioned briefly or in general terms (17, 46, 47, 52) and only a few studies stated them in further detail (48, 49). Overall, five studies dealt with topics of medical professionalism (17, 50-53), five studies were aimed at increasing cultural competence (45-49) and one study dealt with improving tolerance of uncertainty (44). One study on cultural competence focused on treating patients with diabetes type 2 (45), while the other four (46-49) had a wider approach, not focusing on any specific disease.
Evaluation outcomes
The authors of this review assessed the impact of the interventions according to Kirkpatrick’s hierarchy (see Table 1). There was only one study where a change in behavior could be observed (48), the remaining studies only dealt with learning in terms of perceived modification of attitudes/perceptions/knowledge or skills (17, 44-47, 49-53). The mean score was 2, and the median was 2.
To assess the quality of the included studies we used the BEME-guide. Results are summarized in Table 1. The mean score was 2, and the median was 2.
All studies reported having an evaluation component, but in some instances it was difficult, as a reader, to assess this independently since it was only described briefly (47, 52, 53). In these instances, the authors of this review chose to grade the impact according to what the authors of the articles reported, however, we judged the strength of these findings as low.
Table 1. Evaluation of educational interventions aimed at teaching FM residents parts of the informal curriculum.
Score
|
Definition
|
Number of curricula in included papers (n=11)
|
Kirkpatrick’s hierarchy: Impact of intervention studied
|
|
|
1
|
Evaluation of participation
|
0
|
2
|
Learning: Modification of attitudes/perceptions/knowledge/skills
|
10
|
3
|
Behavior: Change in behavior as result of learning
|
1
|
4
|
Results: Change in organizational practice/benefits to patients
|
0
|
BEME: Strength of findings
|
|
|
1
|
No clear conclusions can be drawn. Not significant.
|
3
|
2
|
Results ambiguous, but there appears to be a trend.
|
3
|
3
|
Conclusions can probably be based on the results.
|
5
|
4
|
Results are clear and very likely to be true.
|
0
|
5
|
Results are unequivocal.
|
0
|