The Hidden Curriculum in Which Medical Students Learn to Understand and Manage Unprofessional Behaviour: A Qualitative Interview Study

Abstract

Objectives

Medical students frequently experience unprofessional behaviours (e.g. incivility, bullying), adversely impacting personal and professional development. Formal reporting is rare, suggesting students manage unprofessional behaviour through alternate means. This study investigated the role of a hidden curriculum in medical students’ understanding and management of unprofessional behaviours in medical education.

Design

Third-year medical students were recruited from an Australian medical school. Semi-structured interviews were conducted, and thematic analysis was performed to identify themes in how unprofessional behaviour is experienced and managed.

Results

All 17 participants had experienced unprofessional behaviour, and most had witnessed it directed at others. Only two participants reported these experiences. Four themes were identified. (1) Students rationalised whether an incident was reportable based on severity of unprofessional behaviour, and adjusted their personal standards. (2) They described perpetrator power and position as barriers to reporting, where senior staff committing unprofessional behaviour held sway over students’ medical education. (3) This contributed to perceptions of the fallibility of reporting, that it carried a high risk of negative consequences, with unclear or no reward. (4) In the importance of debriefing, students preferred to manage unprofessional behaviour through informal peer discussions to make sense of their experiences, avoid future encounters, and collectively better understand the culture of medicine.

Conclusions

A hidden curriculum was identified whereby students learn to understand and respond to unprofessional behaviour based on their experiences at medical school. The culture of tolerance of unprofessional behaviour and silence in medicine must be addressed if change is to occur.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40670-024-02208-4.

Introduction

The term unprofessional behaviour encompasses a spectrum of behaviour from incivility to sexual harassment and physical assault [1–3]. Medical students frequently experience a range of unprofessional behaviours during their education [4, 5], with global prevalence estimates of bullying ranging from 30 to 89% [6–8]. Studies in healthcare demonstrate that unprofessional behaviour negatively affects teamwork and communication [9, 10], impacting patient safety and workplace culture [11, 12]. Specifically for medical students, findings from a 2021 scoping review suggested experiencing unprofessional behaviour had negative impacts on the quality of life in the workplace and mental and physical health [13].

Despite the prevalence and impacts of unprofessional behaviour experienced by medical students, approximately 72% of such incidents are not reported [5]. Underreporting can be attributed to student beliefs that incidents are not severe enough, fear of retaliation, and a culture of tolerance of these behaviours within medical education [5, 14].

Medical students learn about standards of professionalism during their education and when on clinical placement. Much of this learning occurs outside the context of formalised teaching. A “hidden curriculum” refers to a set of rules, often implicit, such as customs and rituals, that shape behaviour and values in an institution [14, 15]. As a foundational concept in the sociology of education, the hidden curriculum has been used with Pierre Bourdieu’s concepts of habitus, capital, and field [16] to explore how medical students learn to succeed in a surgical career [17]. The hidden curriculum of medical education plays a crucial role in the professional and emotional development of medical students, the fostering of meaningful patient-physician relationships, and modelling positive clinician behaviour [18]. However, the behaviours that are sometimes demonstrated by doctors and medical educators [e.g., 14, 15] do not always align with professional expectations. In such instances, the hidden curriculum [19, 20] is the means by which students learn their place in the hierarchy and abide by a medical culture where unprofessional behaviours are normalised [21, 22].

While the nature of a hidden curriculum in medical education has been explored, particularly in relation to how students navigate the medical hierarchy [14, 21, 23–27], little research has investigated how students come to understand and subsequently respond to unprofessional behaviour. To address this gap, the aim of our study was to identify and explore medical student experiences of unprofessional behaviour and their approaches to managing such incidents within the context of a hidden curriculum.

Materials and Methods

Interpretivism was used as the methodological orientation for data collection and analysis because of the subjective and contextual nature of unprofessional behaviour and the aim to understand medical students’ interpretations of such behaviour. Accordingly, the study involved qualitative semi-structured interviews. It used inductive and deductive coding to examine the “working hypothesis” [28] that a hidden curriculum mediates medical students’ experience and management of unprofessional behaviour and drew expertise from both insider and outsider researchers to foster intersubjective reflection in the collection of data and interpretation of results [29, 30]. To this end, the research was led by a medical student [31, 32] under the guidance of experienced health services researchers. This study received ethical approval from the Macquarie University Human Research Ethics Committee (Reference:5359). The COnsolidated criteria for REporting Qualitative research (COREQ) guidelines were followed to ensure comprehensive reporting of the study [33].

Setting

The research was conducted with third-year students enrolled in a postgraduate medical programme at a public university in Sydney, Australia. The Doctor of Medicine (MD) programme was established in 2018.

Participants and Recruitment

Third-year postgraduate medical students were recruited during a 2-month period using purposeful sampling. This cohort of 61 students was the third in the medical programme. Students were recruited via email invitations and messages posted on student-relevant social media sites. Those interested were encouraged to contact the researchers to arrange a time for an interview. Participants went into a draw with the chance to win one $50 gift card. Participants were recruited until thematic saturation was reached, which we estimated would occur between 18 and 24 students [2, 6, 34]. Students read and completed consent forms prior to participation.

Data Collection

Semi-structured interviews took place over Microsoft Teams. Participants were informed that the study was being undertaken as part of a medical student research project. Interviews were conducted by a student-supervisor dyad: one medical student researcher (AD, female, Bachelor of Medical Science or YYT, female, Bachelor of Psychology (Honours)) and one research supervisor (KC, female, PhD (Medicine), applied social psychology researcher or RU, female, PhD (Biology), health services researcher). AD and YYT were peers of the participants, enrolled in the same cohort of the MD programme. KC and RU had no pre-existing relationship with the participants and, besides supervising AD and YTT for this research project, had no formal involvement in the MD programme. AD and YYT completed the project as part of the empirical research component of their MD programme; both had experienced unprofessional behaviour in medical education and were interested in investigating experiences and solutions to the issue. They received training in conducting interviews prior to data collection.

The semi-structured interview schedule (Supplementary File 1) included two topic areas: unprofessional behaviour and the specific issue of teaching by humiliation. Findings related to unprofessional behaviour and its hidden curriculum are reported here and include questions exploring participants’ understanding and experiences of unprofessional behaviour, perceptions of its impact(s), and responses. At the conclusion of each interview, the student researcher left, and the research supervisor asked the interviewee if there was anything they would like to add that they did not feel comfortable discussing in the presence of a fellow student.

Data Analysis

Interview recordings were transcribed within Microsoft Teams. Transcripts were downloaded, checked for accuracy, and de-identified. Transcripts were not returned to participants for comment due to time constraints on the MD programme’s empirical research component. Data were coded and thematically analysed [35] in NVivo 20 [36].

A coding framework combining deductive and inductive codes was utilised (Supplementary File 2). Initial coding comprised deductive codes that were developed from existing literature and the interview questions (e.g. knowledge of unprofessional behaviour). In the second stage of coding, key topics in the data that were relevant to the research question but not adequately covered by the deductive codes were used to develop new inductive codes (e.g. unprofessional behaviour and medical culture, severity and reporting). Conceptually related codes were then grouped together to form themes, which were narratively interpreted.

Results

Seventeen third-year medical students were interviewed. Most participants were women (71%) and aged between 22 and 27 (88%) (Table 1). All participants had personally experienced, and 15 participants (88%) had also witnessed, unprofessional behaviour (Table 2). A total of 56 separate experiences were described. The perpetrators of these unprofessional behaviours included doctors, nurses, and midwives. Most experiences occurred during surgery and medical placements. Of the 56 experiences, two had been formally reported. Illustrative quotes of experiences are presented in Table 3.

Table 1.

Participant demographics

Characteristic	n (%)
Gender
Male	5 (29)
Female	12 (71)
Age
22–24	8 (47)
25–27	7 (41)
28–30	1 (6)
31–33	1 (6)
Ethnicity
South Asian	2 (12)
East Asian	5 (29)
South-East Asian	2 (12)
Caucasian	8 (47)
Student Enrolment
Domestic	16 (94)
International	1 (6)
Total Participants	17

Table 2.

Characteristics of the 56 experiences of unprofessional behaviour described by participants

Category	n (%)
Type of unprofessional behaviour
Belittlement	18 (32.1)
Neglect	6 (10.7)
Physical assault	1 (1.8)
Verbal abuse	19 (33.9)
Comments of a sexual nature	4 (7.1)
Sexist comments	6 (10.7)
Comments related to race	2 (3.6)
Experience
Personally experienced	31 (55.4)
Witnessed	25 (44.6)
Reporting
Reported	2 (3.6)
Not reported	54 (96.4)
Total	56

Table 3.

Illustrative quotes of unprofessional behaviour experienced by participants

Type of unprofessional behaviour	Illustrative quote
Belittlement	This doctor walked in, and he wanted to use one of the computers, which is totally ok but just the way he said it…he came straight up to us from behind and said “Move, slaves.” (P17)
Neglect	I think a lot of doctors…they’re trying to do their work and then, you know, they’ve got this medical student following them around…I think it’s easier for them to just ignore the problem. The problem being us, and just focus on their job. But you know, we don’t learn anything that way. So, it’s not…yeah, it’s not great. (P3)
Physical assault	She [nurse] grabbed me by my top and she yanked me out of the theatre, physically. And took me all the way across to the theatre I was meant to be in, bursts in, pointed at the nurse that was inside. She’s like, "you’re not in charge". She looked at the other student that was in there, "You’re not in charge. I’m in charge. If I see this student is meant to be in here, she will go in here." And then she just left. (P9)
Verbal abuse	This nurse bombarded a surgery I was in, asking the other nurse and swearing at her for this ultrasound machine…he burst in was very aggressive, was like pointing and shaking his hand and yelling and swearing while there was a patient on the table about to go under. (P3)
Comments of a sexual nature	They [doctor and patient] were talking about medical conferences. And he [doctor] was talking about how when he’s on the conferences, he and …the other doctors would hire prostitutes back to their rooms … and then he was like, “Oh, what do you think of that [Participant 16]?” You know, “Would you want to come along?” (P16)
Sexist comments	So, one of the consultants was pregnant and another male consultant made a passing comment “Oh, she’s extra hormonal today.” (P12)

Four key themes were identified: perceived severity of unprofessional behaviour; perpetrator power and position as barriers to reporting unprofessional behaviour; fallibility of reporting; and the importance of debriefing.

Perceived Severity of Unprofessional Behaviour

Several students commented that the extent to which an unprofessional behaviour was considered reportable depended on its perceived severity: “It-depends on what the nature of the unprofessional conduct is. If it’s like sexual harassment or assault…you’d be a lot more likely to report things like that than just being yelled at or put down” (P15). As this quote suggests, physical assault and sexual harassment were widely regarded as reportable behaviours. However, some participants who had experienced these unprofessional behaviours, nevertheless, chose not to make a report.

Students acknowledged they had difficulty discerning the severity of their experiences of unprofessional behaviour due to the subjectivity involved and their lack of experience in the medical profession. Participants engaged in conversations with colleagues to better understand their experiences: “You’re also able to discuss and get a sense of what other people think about it and how unprofessional it is because… maybe it’s-actually just a normal thing, maybe it isn’t that bad. It’s a possibility I’m-overthinking it” (P15). Many students questioned their feelings and sought validation through these conversations, which formed part of a larger process where students learned to understand how the acceptability of behaviour can differ within medicine: “It’s hard to know what the norm is and what the baseline is within the medical culture. The culture is strange, and some people are just off. You need-to-obtain-a-barometer of what’s normal” (P9). Most students did not expect to experience unprofessional behaviour prior to commencing medicine: “I do think the mainstream students are probably overly idealistic at the beginning. Maybe you could just say no one really knows what it’s really like when they start” (P5). However, many students indicated their understanding and expectations of unprofessional behaviour in medical culture had changed throughout undertaking their degree:

It [unprofessional behaviour] was much more jarring when I first started medicine because I feel like you’re so much more idealistic. Whereas now it’s like, yeah, this is like a workplace. And of course, unprofessional behaviour is going to happen in any workplace. So, I don’t expect it, but I’m not surprised when it happens. (P15)

Hence, although students indicated severity was an important determinant of whether to report unprofessional behaviour, their own expectations of placements and medical culture had shifted to accommodate these negative experiences. Conversations with peers were an important part of this rationalisation.

Perpetrator Power and Position as Barriers to Reporting Unprofessional Behaviour

Most students identified senior staff as frequent perpetrators of unprofessional behaviour: “the bigger the power difference the more unprofessionalism there may be” (P18). Students believed that such staff operated with impunity, that they “get away with certain unprofessional behaviours just because they have that inbuilt respect, and no one can really speak up against that” (P14). In such circumstances, reporting of unprofessional behaviour was deemed almost inconceivable: “I didn’t really consider it to be an option to be honest. I couldn’t imagine it. He’s so senior. I don’t even know what would happen with that” (P15). Another student shared this sentiment “I felt like I couldn’t speak out against that because this person was so high up…they can just get away with certain things” (P9).

Students acknowledged the hierarchical nature of medical culture was itself a barrier to reporting:

I’m not even sure who I would report it to. I don’t think the person I would be reporting to would be of a higher rank than him. Not that-there is necessarily that strict of a rank…but actually there kind of is though in medicine. (P15)

Furthermore, students noted that there was a lack of clear separation between the academic and support staff responsible for medical students. This created a perceived conflict of interest among interviewees:

It’s very hard to find someone who isn’t sort of involved. Someone completely external to the issue. Someone with no bias whom you aren’t worried about ties, you’re not worried about connections. It’s-so-hard-to find someone who can actually process your report in an unbiased manner. (P17)

This connection between academic and support staff led students to note, “I don’t think people would be comfortable speaking with some of the clinical team, like someone who’s very involved in the program” (P11). As a result, students who experienced unprofessional behaviour had sought staff with no professional or personal connection to the perpetrator, fearing concerns would not be taken seriously or anonymity would not be guaranteed (e.g. the perpetrator would be informed of the report). Students also feared the potential repercussions of divulging their distress to supervisors and assessors, explaining, “if we were to report how we feel, our mental status at the time, we just worry how that might affect our progression within our degree. It’s-this-sort-of subconscious concern” (P6). Several students felt the potential conflict of interest went further when an individual in a dual academic and support role was the perpetrator of unprofessional behaviour, noting, “How could I ever feel supported by [them]?” (P15).

Fallibility of Reporting

Based on the issues described above, students perceived reporting unprofessional behaviour as a high-risk process with no clear benefits. Very few participants had reported unprofessional behaviour and had little knowledge of the process. Most suggested that reporting would not result in meaningful change and feared retaliation: “he would probably know that I reported him. At that point, I still had a couple of weeks of placement with him…and he was my supervisor…he would mark all my assignments.” (P15). Students also felt that reporting unprofessional behaviour after completing a placement would have little benefit to them: “if you wait to finish a placement, so you just spent five or six weeks on placement there, and you had a bad time. What’s the point of passing on feedback? That’s not going to affect you in any way in the future” (P11).

Students often inferred that senior staff had likely been unprofessional throughout their career and reporting would be of little use: “if they have a long history of doing things like that, then you’re more likely again to think, ‘Well if they’ve been behaving like this for 20 years, what’s one report going to do?’” (P17). They further believed that fostering connections and maintaining a good reputation was necessary for career success, whereas reporting senior clinicians for unprofessional behaviour held significant risk:

I think people are quite hesitant to report because it could impact their career in the long-run and even if a more severe-incident-was-to-occur, I think in my situation, I would probably honestly question whether I wanted to report it because I wouldn’t want it to have ramifications in the future for me getting jobs or getting recommendations. I would probably prefer to keep my mouth shut and just deal with the unprofessional behaviour if it meant that I could end up in a job position that I wanted to be in. (P6)

Some participants mentioned speaking to junior doctors about mistreatment and unprofessional behaviour on placement, which seemingly confirmed these concerns:

What I’ve heard from other doctors…is that in their workplace, they have senior doctors who are unpleasant to work with and do sometimes talk down to them and humiliate them …it’s something that they’re not able to complain about because it impacts their ability to get references and excel throughout their career. (P6)

These conversations contributed to student perceptions that unprofessional behaviour is tolerated and reporting carries a high degree of risk. Participants described a widespread concern that, due to the small cohort of students in their programme, they might be identifiable by a clinician regardless of steps taken to ensure anonymity:

There’s… this theoretical idea it won’t come back to bite you because it’s anonymous, I’m not sure that’s really true. I think there’s a fear that because there are only a couple of people on a given placement, if feedback goes back to a supervisor, they only have a few people to look at who could be implicated in that feedback…it becomes obvious… who is reporting or where in the chain it’s sort of been passed on. So, I think as much as it’s ‘anonymous’ we’re such a small group it can’t really be anonymous. (P11)

Due to the limited experience with formal reporting, most participants were only able to speculate about how this process would unfold, and raised concerns that clinicians could be told who had reported them: “What happens after you put in a report?… ‘What if the person finds out?’ Not just that they receive the report but also what if they find out who reported them and therefore what could happen to you.” (P17).

The Importance of Debriefing

Many participants stated that they discussed their experiences of unprofessional behaviour with their student colleagues as a form of peer support: “you end up feeling better with the discussions…which I think is probably what most people are looking for. They’re looking to feel better after the negative experiences” (P16). These discussions allowed students to better understand their experiences:

I talked to process what was happening and kind of debrief. To be able to go, ‘What was this?’ I don’t do it with the intention of reporting or enacting change. It’s more a case of I need to get it off my chest. (P16)

These conversations were considered “safe spaces” and were preferred over formal reporting processes: “because it feels easy and it feels comfortable and it feels safe to do it in that environment” (P2). These conversations were typically had with other medical students because conversations with senior staff “may make you feel like you’re just being heard for the sake of it, as opposed to actually having your feelings properly heard” (P11).

Moreover, participants valued the sense of camaraderie through shared experience these conversations brought: “I just want to check that I’m not alone in my experiences” (P6); “If you tell others, it’s not …all on you. You’re kind of sharing the burden of it” (P14). Students used these informal debriefing sessions not only to feel understood and valued, but also to further inform their understanding of medical culture and its hidden curriculum: “We need to stick together. We need to have those shared experiences because it’s another way of learning” (P2), and “it’s like a group therapy session” (P8).

Many students chose to discuss experiences with one another, rather than through formal pathways due to the inability to control the latter process and the risks involved. Moreover, some participants suggested these conversations could serve a purpose in forewarning students about recurrent perpetrators:

So previously, my colleagues have told, like warned us because she … had a placement with this particular clinician, who proceeded to sexually harass my friend, who then reported this case to the faculty. And also warned us if we get him for teaching, you know, this could happen. (P18)

Peer debriefing was, therefore, an opportunity to respond to unprofessional behaviour in a safe environment without the challenges associated with reporting.

Discussion

We aimed to examine medical students’ understanding, experiences, and responses to unprofessional behaviour during their education. We found that, despite unprofessional behaviour being widely experienced while on clinical placements, students rarely reported it. A hidden curriculum was identified that led students to rationalise unprofessional behaviour according to severity and the hierarchical culture of medicine. Due to perceived barriers and potential repercussions of formally reporting unprofessional behaviour, students favoured informal peer debriefing to manage these experiences.

Unprofessional behaviour was viewed by participants as an inherent aspect of medical culture. The rationalisation of unprofessional behaviour in medical education as essential or unavoidable has long mitigated attempts to address it [6, 37, 38] and has been justified as serving a functional purpose, compared to military “hazing”, used to “weed out unfit interns” (p. 205) and prepare students for a demanding career [39]. Furthermore, participants in our study were, except in very extreme cases, not always certain about what behaviours constituted unprofessional behaviour. Past research by Gan and Snell [2] similarly found that medical students differ in their perspectives of mistreatment and highlighted the subjectivity involved in identifying such behaviours. This presents a potential barrier to reporting, because reporting relies on students having the capacity to both recognise that they were the target of unprofessional behaviour and believe there will be no negative consequences arising from speaking up [40].

A spectrum of mistreatment of medical students has been proposed [2], ranging from blatant, “incident-based” mistreatment such as verbal, physical, or sexual abuse through to “environment-based” mistreatment that includes common subtle experiences like subjective feelings of disrespect or being ignored [2]. Students have suggested they have more power to report “incident-based” mistreatment compared to “environment-based” mistreatment since the latter is perceived to be outside of institutional definitions of mistreatment and, therefore, harder to report [2], despite evidence of negative impacts on learning, patient care, and marginalisation [38]. In the present study, students not only characterised their experiences based on perceived severity but also increased their tolerance for what constituted unacceptable behaviour within medicine, partly through discussions with peers. Student adjustment of personal standards to assimilate into medical culture has been characterised as students becoming “professional and ethical chameleons” [39]. Junior members of the medical team may learn to accept unprofessional behaviour to the extent that it is normalised once they become doctors, which has been argued to lead to a “cycle of abuse” where these once-abused students become the perpetrators: “abuse begets abuse” [6].

Our participants viewed reporting unprofessional behaviour to be low yield and high risk, with potential consequences in retaliation or to their professional reputation and career progression. These issues have been echoed in past studies [6, 41–43]. Only two participants had formally reported unprofessional behaviour, and all students held concerns about their psychological safety, informed by their recognition of a hidden curriculum that dissuades and potentially even punishes students for talking about what they witness. Moreover, none of our participants were able to articulate the formal reporting process available to them or even confirm if one existed: the two participants who reported their experiences of unprofessional behaviour explained they approached “friendly staff” to initiate the reporting process.

In the absence of a viable formal recourse, research suggests that medical students may respond with coping strategies such as avoidance and compensatory behaviours like self-blame or justification of perpetrators’ behaviour that can paradoxically increase distress [44]. Our study identified an additional tool for managing these experiences where students seek support from other students by conducting peer debriefs. Compared with formal reporting, debriefing with peers was described as a safe space for discussion about unprofessional behaviour, one that allowed participants to learn from, bond with, and warn their peers about experiences on clinical placement. Bell and colleagues, in their constructivist grounded theory of medical students’ experiences with deciding whether or not to report mistreatment, highlight the importance of feedback and support of other medical students in this journey [26].

Implications

Our findings underscore the importance of conversations with peers and with other healthcare professionals in supporting medical students to informally manage their experiences of unprofessional behaviour. However, such conversations may act as a double-edged sword; our results suggest they normalised unprofessional behaviour and led to the maintenance of the status quo because students were both warned about potential perpetrators and utilised peer debriefing as an alternative to reporting. Incorporating education about unprofessional behaviour into medical education, including guidance on how to identify these behaviours and the processes in place for reporting them, may mitigate these issues. Peer discussions might then be utilised as part of this education; student-facilitated learning sessions about medical student mistreatment have been introduced at Boston University School of Medicine [45] to increase awareness of what constitutes unprofessional behaviour, troubleshoot, encourage reporting, and provide anonymous feedback to the medical faculty.

Clear guidelines are critical to facilitate the process of reporting and improve transparency [6, 46]. Our findings demonstrate that students are aware of staff positions, relationships, mentorships, and friendships and consider these prior to reporting, reinforcing the importance of anonymity and assessment of conflicts of interest in staff who are delegated as academic and support staff. Other reporting processes should also be considered. For example, confidential online reporting systems have been implemented successfully in hospital settings [47–49] and recently introduced specifically for trainees in a large academic medical centre [50]. Peer-to-peer reporting systems have also been proposed [44], given that students already utilise peer debriefing and, therefore, are likely more inclined to interact with a peer, as opposed to a staff reporting system.

Strengths and Limitations

The strengths of this study include that interviews were conducted by a medical student supported by more experienced health services researchers, allowing the topic to be examined from an “insider” and an “outsider” perspective, respectively [51]. The medical student interviewer was easily able to establish rapport with participants and was recognised as inherently familiar with the subject matter, leading to more open discussion; on the other hand, the experienced researcher, as an “outsider” and unfamiliar to interviewees, was able to interject with additional questions where tacit, shared knowledge between lead interviewer and interviewee left key information unsaid [52]. These insider and outsider perspectives were also leveraged in the interpretation of results, as research supervisors met regularly with student researchers during the analysis phase and reviewed transcripts, the emerging coding framework, coded data, and the written analysis to add further perspectives to the interpretation and enhance credibility. The research was also conducted in the context of a recently established medical programme, demonstrating that the dynamics of a hidden curriculum affecting the management and reporting of unprofessional behaviour do not take long to develop.

This study has some limitations. First, all students were recruited from a single medical cohort; and therefore, some findings may be unique to the cohort. However, clinical placements occurred across a variety of healthcare settings, and many findings are consistent with other studies, suggesting they may be applied more broadly. Secondly, while the study did not exclude students who lacked personal experiences of unprofessional behaviour, the recruitment messages detailed the topic to be discussed and, therefore, may have appealed more to students who themselves had experiences of unprofessional behaviour. This may explain the overrepresentation of women (71%) among the interviewees when the larger cohort has an approximate 50:50 gender distribution. Research suggests that women experience higher rates of incivility and bullying during medical education [7, 8].

Conclusions

Our study provides insight into the hidden curriculum that influences how medical students understand and respond to unprofessional behaviour in medical education. Students integrate into a culture that tolerates unprofessional behaviour, and they adjust their expectations and standards accordingly. Acceptance of the medical hierarchy, ambiguity about acceptable behaviours in a clinical environment, and fear of retaliation limit student reporting of mistreatment. To address these issues, medical student education should include explicit guidance on what constitutes unprofessional behaviour along with a commitment from medical schools to provide transparent and confidential channels to report unprofessional behaviours experienced. Further research on the dynamics and impacts of peer debriefing is needed and might be leveraged in the future to encourage addressing unprofessional behaviour in medical education.

Supplementary Information

Below is the link to the electronic supplementary material.

Author Contribution

KC, RU, RM, and JIW had the original idea for the study. All authors contributed to the study design. AD and YYT collected and analysed data, supported by KC and RU. AD drafted the manuscript. All authors critically revised the manuscript and approved its final version.

Funding

KC is supported by a National Health and Medical Research Council Emerging Leadership Fellowship (2007765). JIW is supported by the Elizabeth Blackburn Leadership Fellowship (1174021).

Data Availability

The datasets generated and analysed during the current study are not publicly available due to ethical restrictions related to confidentiality and data sensitivity but may be available from the corresponding author on reasonable request and with appropriate ethics approval.

Declarations

Competing Interests

The authors declare no competing interests.