Students’ and Faculty Perspectives Toward the Role and Value of the Hidden Curriculum in Undergraduate Medical Education: a Qualitative Study from Saudi Arabia

Abstract

A hidden medical curriculum is defined as the unwritten, unofficial, and unintended learning that students experience in medical school along with more formal aspects of education. This term describes the behaviours, attitudes, assumptions and beliefs conveyed by teachers, peers and the surrounding environment. However, more research is needed to evaluate its impact on student and faculty interactions in this context. We conducted this qualitative study utilizing focus group and semi-structured interviews of students and faculty to evaluate the perspectives of medical students and faculty toward the role and impact of the hidden medical curriculum in medical education at Alfaisal University, Riyadh, Saudi Arabia. Data was analysed using open-, axial- and selective-coding using thematic framework analysis. Interviewees consisted of 24 students in years 1–3 during the spring semester 2018–2019, 8 faculty members and 4 teaching assistants. We identified six core themes of hidden curriculum at Alfaisal University (Appendix). Role and behavioural modelling, value-based teaching, interpersonal faculty-student interactions, effects of diversity and socialization, teaching methodologies and hidden curriculum, mentoring and student support systems. Although some of the themes identified in these focus group interviews were similar to previously published studies, the novel themes that we identified were diversity, socialization and interpersonal faculty-student interactions. We conclude that identifying the issues pertaining to hidden curriculum is important for the development of medical students and for nurturing and upholding the values that we want to instil in our future physicians.

Introduction

A hidden curriculum is defined as the “unwritten, unofficial, and unintended learning that students experience in medical school along with more formal aspects of education” [1]. This term describes the behaviours, attitudes, assumptions and beliefs conveyed by teachers, peers and the surrounding environment [2]. This aspect of medical curricula plays an important role in humanizing medical education, while also reinforcing the importance of socialized medical education and training [3]. Usually viewed as a separate entity, such information is unintentionally transmitted throughout all stages of formal medical curricula [4]. Thus, attempts to influence the hidden curriculum should start by changing the formal curriculum [3]. Investigating the efficacy of hidden medical curricula is driven by educational institutions striving to develop synergy between hidden and formal curricula, directly affecting the practice of medicine [4]. The hidden curriculum has several educational outcomes that have been characterized as lasting, powerful and at both extremes: positive and negative [4].

Several studies have emphasized the importance of the hidden curriculum in shaping students’ professional identity [5, 6]. Often, the hidden curriculum in the clinical learning environment conflicts with the formal curriculum, and students usually note these differences especially when the gap involves ethical and professional matters [7]. Students tend to internalize behaviours and values that are modelled by their peers and faculty during their undergraduate years [7]. Hidden curriculum with positive values presumably aids in development of critical thinking skills, empowering students to make active choices from their surroundings. This in turn influences patient-physician interactions and successful clinical reasoning [5, 6, 8]. Indeed, effective interaction between patients and doctors consists of more than words, and the hidden curriculum fosters the desired emotional communication and empathetic understanding [8]. According to Silveira et al., physicians can change behaviours that do not align with patients’ best interests when they openly discuss the hidden emotional aspects of patient care with their students [9]. Currently, there is an increased awareness among educators about the need to understand the hidden medical curriculum and its impact on faculty and students.

Given the lasting impact of the hidden curriculum on medical education and training, alongside clear benefits on student development, exploring the role and value of hidden medical curriculum may prove valuable in medical education [10]. To the best of our knowledge, such investigations have yet to be performed in any educational institution in Saudi Arabia and the Arabian Gulf region. Moreover, a majority of previous studies describing the hidden medical curriculum have focused on analyzing how students perceive the hidden curriculum in their environment. In contrast, the perspectives of educators have received minimal attention. The aim of our present study is to evaluate the perspectives of medical students and faculty toward the role and impact of the hidden medical curriculum in medical education at Alfaisal University, Riyadh, Saudi Arabia.

Methods

Study Design and Setting

A qualitative study design consisting of focus group interviews for students and semi-structured individual interviews for faculty was implemented. The study was conducted at the College of Medicine, Alfaisal University, Riyadh, Saudi Arabia. Alfaisal University was established in 2008 and has a diverse population with over 39 nationalities represented on its campus. A purposive sampling method was employed to recruit participants by sending out an email to medical students, faculty, and teaching assistants [junior faculty recruited from Alfaisal Alumni]. Those who responded to the email were contacted through phone to explain the purpose of the study. Once they agreed to the interview, a date and time was finalized, and location was sent to them on the day of the interview. The location was one of the meeting rooms in the college of medicine (COM). Interviews were continued until saturation was achieved, that is, no new themes emerged.

Ethical Considerations

All relevant ethical requirements set out by Alfaisal Institutional Review Board (IRB) were fulfilled and IRB approval was obtained (IRB approval number 18083). Participation in this study was voluntary, and confidentiality and anonymity were promised and maintained. Written informed consent was obtained from each student and faculty member who participated in this study. To maintain the confidentiality of data, the audio-files and transcripts were anonymized. All analysis was performed without any identifying data of the participants.

Data Collection

We collected our data through focus-group discussions [students, 6/group] and semi-structured individual interviews [faculty]. All interviews were conducted in a private setting within the Alfaisal campus. We developed our interview guide based on our initial literature review and focused on four main aspects: recognizing the hidden curriculum, personal experiences of different aspects of the hidden curriculum, present gaps in the structure of the hidden curriculum and coping with challenges and difficulties. Specific questions were used as prompts based on the interviewer’s judgement. Students’ group discussions averaged 90 min in duration while faculty interviews were of shorter duration (~ 20–30 min).

Data Management

All interviews were recorded by two co-authors on two different cell phones. The audio-files were transcribed using “Live Transcribe” and then further transcribed verbatim by co-investigators. The audio-taped interviews and their respective transcriptions were stored as password-protected files on the official computer of the principal investigator at his workplace.

Data Analysis

Data was analysed using open-, axial- and selective-coding under constant comparison procedure utilizing thematic framework analysis [11]. Analysis began after 4 interviews were conducted and continued simultaneously as further data were collected until no new themes emerged. That is, we achieved data saturation. Each transcript first went through a process of open coding during which we read the transcript line by line repeatedly, described open codes, recorded examples of participants’ responses and established properties for each code. For each cycle of data collection, we explored how the identified open codes were related to each other and grouped them into main categories, consistent with axial-coding procedures. Then, memos were generated based on our ideas and thoughts while interacting with the data during the open- and axial-coding.

Throughout the afore-mentioned process, a constant comparative analysis was conducted. Codes were constantly compared with other similar codes for similarities and differences; thus, as categories were generated, the integration of these categories into core themes was occurring simultaneously. Memos were included in this analytical process. Transcripts were reread and responses were coded selectively based on the identified core themes. Figure 1 shows methods flow chart.

Fig. 1.

Methods flow chart

Results

The total study sample included 36 participants [50:50 males/females] consisting of 24 students in years 1–3, eight full-time faculty members from the college of medicine and four teaching assistants. Six major themes emerged in our study: role and behavioural modelling, value-based teaching, interpersonal interactions, culture and socialization, teaching methodologies and hidden curriculum and challenges and student support system. Here, we discuss the results from our thematic analysis supported by selected representative extracts from the participants’ responses. All quotes are in italics and ellipses are used in place of all utterances, stutters, pauses and other forms of non-verbal communication for clarity.

Theme 1: Role and Behavioural Modelling

Most of the students’ responses described positive role models. Students mainly discussed professionalism, responsibility, commitment to excellence and effective communication during sessions as the most attractive features in their role models.

Motivation to help fellow students, encouragement to learn and work harder and an increased sense of responsibility to be more professional were reported as influences of these positive encounters.

One student had this to say on this theme: “the most prevalent thing in Alfaisal faculty … the way they guide students … they guide them to be more professional …at my first year in Alfaisal university I was wild … going wild, but at the end, I can feel that … I changed, I became more like … disciplined if I can say… more professional”.

Also, another student stated: “From the beginning, I put to myself that … when I get to the first year I will help the UPP [University Preparatory Program] students as much as the first-year students helped me and every year the same.”

Few reports of negative role models in the form of lack of professional behaviour were also coded from students’ responses. Students criticized such poor behaviours and were motivated to be more professional after any such encounters, but their behaviour changed albeit unintentionally. One student stated: “I got this behaviour from him without intentionally paying attention that I'm doing the same thing, which is wrong, then later on… like … oh! I am doing the same thing… this is wrong… I have to correct my behaviour.”

Faculty members talked about themselves as role models and how they viewed role modelling as a mean of teaching professionalism. All faculty members highly appreciated their responsibility, as instructors, for modelling appropriate behaviour and consequently developing desired behavioural outcomes in their students. One participant mentioned: “As a faculty with an experience even outside Alfaisal University, I know that you should be a role model … because you’re teaching young students … you know you are influencing them, so you should always be careful with what you say, what you do, … and I have it always in the back of my mind.”

They also identified respect to others, punctuality, compassion, hardworking and empathetic relationships with patients as attributes educators should seek to appropriately model for their students. As one faculty member noted: “I think they need to see role models who are competitive, high achievers, respectable, and who have good values… they will be affected by their attitude, their approach to things, their norms. So, I think role models will have a very good influence on the students.”

Most of the faculty believed behavioural modelling by clinical faculty has a major contribution towards instilling the desired outcomes in students. One of them reflected on that by saying: “Behaviour of the clinical faculty is very important because they are role models for the students … and their interactions during patient care and ward rounds and clinics …. is more important.”

Although they appreciated the responsibility for modelling appropriate behaviour, some questioned the effectiveness of the current situation in terms of whether students and faculty have the needed awareness. One argued that: “I think there is very little awareness among the students and faculty about what they are transmitting to the students.”

Theme 2: Value-Based Teaching

This theme emerged when faculty members commented on the values that students need to develop as future physicians and how they incorporated these values into the teaching process. Excellence in patient care was the most frequently reported value. This was described in terms of empathy, respect, responsibility, openness, integrity, confidentiality and effective listening. They also talked about the importance of morality and keeping knowledge up to date. In this regard, some representative comments are listed in Box 1.

The faculty members also spoke about professionalism and respect when dealing with colleagues and seniors in the profession. As one participant stated: “Being a multinational University both from students and teachers, I think respect for others… who are different from you is very important.”

Research ethics were also reported as values that students should be encouraged to acquire and practice. One faculty member said: “I think we could do better in encouraging this culture of research through the hidden curriculum because in research you have to talk about many things … how to be an active seeker for information, how to … be well-grounded in what to do and what not to do.”

Finally, behavioural modelling, formal teaching and managing the culture of the educational environment were all reported as effective means of incorporating these values in the teaching process. One faculty member commented: “We teach a lot of history, to do with scenarios that will have something that students are not usually aware of … to show the students that patients are different and to give them a message that you never judge patients.”

Box 1 Selected Comments on Theme 2: “Value-Based Teaching”.

“The respect of the patient and respect of the community … how to handle patient information ... respect of the patient in the sense of how you behave with the patient and how you handle patients’ private information... and when we say that with community... it is very important how to respect others’ opinions ... how to communicate your opinion ... and how to keep things transparent.”

“I think there should be a sense of openness and sharing …I think the ... relationship that you build ... and the feeling that comes out of that dialogue that you have with the patient is a lot more satisfying than ... just saying … take this medication come back see me in three weeks if everything is okay don't come back.”

Theme 3: Interpersonal Faculty Student Interactions

This theme emerged when students commented on the characteristics and influences of their interactions with faculty members, their peers and university officers and staff. Students mainly described positive, open and friendly, yet professional relationships with faculty members. As one student mentioned: “The very professional yet very personal relationship that we have with our professors is also giving us the stimulus to develop our professional behaviour that we are going to have to put on whenever we enter a hospital… it gives us essentially the confidence to convene with consultants, specialists, and other medical practitioners.”

All students agreed that most of what they learn in their educational environment comes from their cooperative and friendly interactions with their colleagues. Many cooperative activities including the PreMed summer program, peer-assisted learning sessions, student clubs and labs and problem-based learning (PBL) session committees had a tangible effect on students in both academic performance and personal development. One student commented on that by saying: “PreMed … the ideal situation where the people who are teaching from their free time … they're giving… us, and the people are helping as well.”

In almost all the interviews, academic competition was reported as another major characteristic of peer-peer interaction. Most students felt that this competition motivated them positively to work harder, but some of them viewed this environment as potentially harmful. One student said: “What motivates me is the competition among us, I feel like the healthy competition”. Another student argued: “I feel like there's a lot of competition between students …So that provides either motivation for the student or when the plans don't turn out to be the way that student anticipated, a massive hit to the ego.”

Finally, many students agreed that they appreciated a positive influence when they were able to approach anyone in the administrative branch including the dean and the president. As one student mentioned: “the OpenOffice policy or the open-door policy I believe … it's great … when the university president is… you can go to his office and … ask to meet him, to talk about almost anything … it's kind of implying the idea that… everyone regardless of his position should be approachable.”

Theme 4: Diversity and Socialization

One of the most important features that characterize Alfaisal culture and society is being multinational at the level of both students and faculty. Over 39 nationalities are represented now on Alfaisal campus. All students in all interviews responded positively when this multinational nature of Alfaisal culture was discussed. Students mentioned that this cultural diversity positively helped them in acquiring and learning social interaction skills and other skills required for real-life situations and increased tolerance to others.

As one student said: “when you come to a university, you'll have to deal with a lot of different people from all over the world and with so many different religions … ethnicities…that, in general, enforces acceptance… and gives you an open mind when dealing with situations now that could help you a lot as a doctor.”

We defined “socialization” in this study as the act of adapting and adjusting personal behaviour to the norms and values of a society to which someone belongs. Students’ personal experiences of adaptation to the norms of the medical profession seemed well supported by Alfaisal environment. As one student said: “Opportunities here are a lot, whether it's volunteering … research, there's always something for someone, so if a person looks then there is a lot of opportunities that he could learn from.”

Some students described changes in their appreciation of social relationships and family time, but the majority mentioned feeling more socially detached as they grow in medical school in the context of them developing their time management skills. One student said: “I feel like I'm selfish with my time … Even … the time where I can be spending it with my family, I feel like to gain back the energy to return to the studying I have to spend it with myself on my own.” Another student argued: “Unlike feeling detached from my family, I'm more now with them because now I value … it’s either now or never… more appreciative of the present time and take things slow, more patient.”

Theme 5: Teaching Methodologies and Hidden Curriculum

We coded responses under this theme when they were describing any aspect of the formal curriculum as a factor related to the hidden curriculum. Participants mainly talked about how designing a certain teaching method must reflect important behavioural outcomes for students as future physicians. The most frequently mentioned example is designing and utilizing team-based learning (TBL) activities to foster the importance of teamwork in medical practice.

Teamwork appreciation, social skills development and professional identity development were reported as vital outcomes that complement students’ behavioural development. One student noted: “PBL and TBL have also effects on … teamwork, communication skills, clinical decision-making, professionalism.”

Besides, some participants mentioned that incorporating some of the hidden curriculum messages into the assessment process will promote the value of these messages. As one faculty member stated: “We should be able to incorporate … some ethical issues, some humanity related concepts … we have to add some objectives related to it… because if they would be part of our objectives… they will be assessed.”

Theme 6: Mentorship and Student Support Systems

We coded under this theme all responses describing challenges facing students and different observed forms of support systems. Participants mentioned a variety of challenges that medical students struggle to overcome. They mainly talked about difficulties in coping with the academic workload, acquiring the desired professional attitudes, and dealing with the dissonance between expectations and reality.

All faculty members viewed the multicultural nature of the educational environment as an added value in which students grow and develop in many aspects. One of them commented: “I think this is a bonus for Alfaisal University … if we have diversity … you are set for the world … you will be confident, exposed, knowledgeable, flexible you will be diverse wherever you go so I think this is a very healthy environment.”

Most of the faculty members agreed that faculty play a major role in supporting students throughout their education mainly through the mentorship program. One faculty member reflected on that by saying: “Alfaisal university faculty are … giving a lot of guidance information to the student and through mentorship program and… I think these challenges are easy to overcome, I think Alfaisal University is very lucky to be in this environment as they're very close to the faculty … where doors are open for them all the time … I feel the environment is very healthy and supportive for the student.”

Also, students’ cooperative activities, extracurricular activities, socialization and student empowerment and engagement were all reported as effective means of support and encouragement for the students. As one faculty member said: “I'm impressed because I see most of them work as a team … they have the MSA [medical student association] teams, the batch leader, the notes committee, the transcription committee, and these beautiful resources that they share with a batch … I think this is one of the most important survival skills.”

Discussion

Our main aim was to explore the students and faculty perspectives toward the hidden curriculum and the themes identified in our study are consistent with the main factors that influence the hidden curriculum previously described [12, 13]. We have divided the discussion into student perspectives and faculty perspectives on hidden curriculum.

Student Perspectives

In our study, students appreciated the value of role and behavioural modelling in their development by narrating mostly positive experiences and reflecting on negative ones. Students considered that values modelled in their environment motivated them and shaped their professional identity, acknowledging vulnerability when encountering negative models as they found themselves unintentionally reproducing behaviours that do not reflect their values. Many similar studies have demonstrated similar attitudes and recognized role modelling as a major contributor to the overall student development [1, 7, 9, 14, 15]. Moreover, role modelling has a crucial impact on students’ professional development, which is powerful but subconscious [16].

Interpersonal relationships were highly appreciated as learning and developmental sources at various levels. An open and friendly relationship with staff and faculty members was described as supporting and encouraging. Cooperative activities and academic competition were mostly viewed as positive features of peer-peer interactions. Such degrees of collegiality are needed between students and teachers to facilitate students’ professional development [1, 9, 14, 15, 17]. This finding is described previously highlighting the importance of cooperative peer-peer relationship and the inventible existence of competitive environment in medical education [1, 7, 15, 18, 19].

The multicultural nature of the educational environment was acknowledged by all students as a highly positive influence. As doctors are required to provide fair and equal care to all patients, learning how to manage social diversity is a must-have skill for all medical students. Students showed awareness of how they were adapting to the norms of the profession and how they were developing empathy for patients. This was also reported in some previous studies [2, 9]. Students also recognized the importance of medical research and appreciated how their environment encouraged them to get engaged in research. In our context, students are offered open and ample opportunities to train both in the research centre of our affiliate hospital and at the university [20].

Finally, students’ interviews showed that they were aware of how formal curriculum elements can influence the hidden curriculum. They described exposure to a variety of educational activities and the behavioural outcomes they gained or expected from these activities. The most recent model of medical hidden curriculum management developed by Yazdani et al. recognized the formal curriculum as an important “signal transmission source.” They articulated its importance in terms of alignment of course organization and teaching and assessment methods with missions and values of medical schools [12].

In our study, students were clearly aware of the effect of the hidden curriculum on them as reported in several other studies [1, 7, 10]. However, they were unconscious of it as an established structure and part of their curriculum. Educating medical students about the hidden curriculum and encouraging them to reflect on it seems necessary [1, 7, 21, 22]. This study clearly emphasizes the fact that some components and frames of the medical hidden curriculum are evident in all medical schools across the world [1, 7, 14, 19, 23, 24].

Faculty Perspectives

The faculty were unanimous that they see themselves as both role models and mentors to their students and they appreciated both roles. This has been also acknowledged by participants in previous studies [7, 12, 25–29]. Weissmann et al. concluded in their qualitative study that role modelling is the primary tool through which excellent clinical faculty teach their students the humanistic skills of patient care [29].

Participants also talked about using the hidden curriculum as a mean of forming students’ professional identity and transmitting ethical values. Similar findings were emphasized in other studies and were reported by students in their interviews [7, 12, 25, 26, 28, 29]. Our participants also reflected on how this transmission of skills and values should occur and the views expressed were in concordance with previously published studies [7, 28]. Values such as teamwork, sense of responsibility, integrity and research ethics were identified which are like previously reported values. Role modelling was the most frequently mentioned method of transmitting these values rather than teaching [16, 25].

Also, faculty were aware of and recognized the hidden curriculum as the main source of acquisition of attitude by students in their clinical years which is consistent with the modern model of hidden curriculum management developed by Yazdani et al. [12]. In their model, Yazdani and colleagues described the formal curriculum as a “sender of signal” in which its various elements should align with what should be conveyed through the hidden curriculum. This includes correspondence between course design, teaching style and assessment method with values of the hidden curriculum which was reported in our study. Finally, participants appreciated the importance of student support systems and recognized their role in this respect. This was also reported by participants in a previous study [1, 7, 12].

Although the hidden curriculum is known to have both positive and negatives influences, the participants in our study had a positive perspective towards the hidden curriculum [4, 28]. Moreover, the themes that emerged in our study covered most of the conceptual boundaries of the hidden curriculum (interpersonal-social, contextual-cultural and motivational-psychological) described previously [25, 30]. Also, reflective learning, in the form of having the skill to take a negative experience and redefine it as a positive learning opportunity, was thoroughly described in the literature as an important tool to address and manage the hidden curriculum in any educational environment. Lastly, there is a rising understanding that the hidden curriculum does not affect students only and that educators should be considered more than mere deliverers of messages. This was first described by Hafler et al. in 2011 in which they talked about the process of faculty socialization and how educators should understand the hidden culture in their institution and how they can manage the conflict that arises from this culture in their workplace [13].

The findings of our study demonstrate that faculty members have an adequate appreciation of their role in promoting the desired outcomes from the hidden curriculum in parallel with what they must teach through the formal curriculum. Although the term “hidden curriculum” was not recognized by most participants, their responses showed that they have been using its different elements to support their students’ development. We believe that awareness regarding the hidden curriculum needs to be further nurtured among medical faculty [10, 25, 30].

Conclusions

We conclude that addressing the hidden curriculum is important and of a clear necessity for the development of medical students and for nurturing and upholding the values that we want to instil in our future physicians. The understanding of the hidden curriculum from student and faculty perspectives seems to have an influential role in improving medical hidden curricula. The results also highlight the evident need to raise awareness about the hidden curriculum as a structure that can be actively tailored to potentiate positive outcomes and minimize negatives ones. This could be achieved by including the discussion of different aspects of the hidden curriculum in students and faculty development programs.

Appendix. Selected participants’ comments regarding the hidden curriculum and its six identified themes

Theme 1	Role and Behavioural Modelling Faculty and Student quotes:
	“Like the physicians … especially the female physicians.. clinicians that usually come in really inspire me in the way they hold themselves, the way they talk about their subjects, how much they love their profession, I really enjoy it.” A Student
	“I think… of course, we can teach by being an example… we can teach by being a role model.” A faculty
	“There are doctors that come and they were talking in such a way that will motivate you to be like this person […] Although family medicine is not something I'm thinking of doing but still, the way he (a family physician) carries himself and the way he talks about patients and the way he talks to the students speaks volumes. And other professors that are really respectful to students, like it is a mutual thing.” From a student in Focus group interview
	“Most of our doctors are like trying to push us forward by telling us indirectly that all of us here are smart all of us can do it we just need to put in the effort.” From a student in Focus group interview
	“I also agree … when female clinicians come and show up and they are very enthusiastic they are really giving us a good impact.” From a student in Focus group interview
	“Sometimes, the presence of teachers or anyone that teaches us and gives us knowledge can be quite insensitive because they're so used to being in this Environment. so sometimes I would be shocked in forensics how they talk about cases and other subjects I'll be shocked how they like they are talking normally this is how they are it's just how the profession is. it makes me alarm like: I don't want to become like that, I don't talk to people that are not exposed to this new information in such a way.” From a student in Focus group interview
	“I think all teachers need to be trained to watch and observe because all teachers for me are role models they will imprint their effect on the student one way or another, so maybe teachers all through all levels of education needs to be aware of their influence other than the education the learning process.” A faculty perspective
	“I always try to come on time and I always like respect everybody's.. viewpoint okay? I never.. whether somebody is saying right or wrong.. I never interrupt them in between … like the punctuality.. it should be.. like.. it should be.. practiced by every everybody.. like the.. like for the PBL facilitators ok? timing is very important.. it should be.. followed by all whether they are junior faculty or senior faculty … and they should not be humiliating.. the.. the low achieving.. achievers in the class in front of them.. they should not give feedback in front of others.” A faculty perspective
	“When I talk to students who have difficulties you know whether it's you know difficulties academic or personal I think we're always trying to be a role model and giving them.. a lesson in life” A faculty perspective
	“You could use role model but make that role model thing more explicit.. make it come from.. the.. from the value system of the students.” A student quote
Theme 2	Value Based Teaching
	“Things like… you know… morality and ethical treatment of your patient … that is all you know … something that everybody does … you know in terms of … you know respect and confidentiality … and … and the kind of behaviour you have with a patient is something that's taken as given.. okay? … and then you add on to all of that … this other bit that I'm talking about in terms of you know having a sympathetic ear … being empathetic … and making sure you are up to date.” From a student
	“I think …that the best way.. one of the ways would be to role model … another thing that can be done is.. where we actually expect the students in other words.. you don't necessarily teach them to do something but you put them into the situation where they need to be more empathetic.. all right? and then look at how they cope with this particular situation.” From a faculty
	“As a university I think we need to focus on the professional values, values of professionalism … we need to pay attention to the values of being a professional person in terms of acknowledging your weaknesses and acknowledging your strengths in terms of knowing vulnerability whether it's your vulnerability or another person vulnerability and not abusing it.. I think also common sense judgment.” A faculty perspective
	“I tried my best like at least they should know.. number one they should know how to respect their peers their teachers their faculty their friends they should know that they should respect the others opinions this is something and as you said it's a multicultural multi opinion of course either it is a faculty or either the student themselves they should I think this is what I always try to do that they should learn how to be respectful how to approach correctly.” Student
	“I think that.. what students need to see and.. which in terms of the formal curriculum is.. is not necessarily taught.. but that value for me is.. is empathy.” A faculty perspective
Theme 3	Interpersonal Interactions
	“As far as students are concerned, it shaped my values 180 degrees because you'd come and see people go through the same challenges … but from a different perspective and that would add to your values because, you know, this is your mind once you start talking to people you have now two minds and three minds, so your perspectives grow and you start seeing the world differently.” A student
	“One of the things that I really like is that most of our doctors when you look at their resumes you'll find a long list of achievements yet when you try to talk to them you feel like they're normal people and that helps a lot … most.. most of our doctors are really laid back they don't really care and they really try to help you as much as possible most of the time.” A student
	“The.. huge bulk of the hidden curriculum we learn from interacting with other colleagues.” A student
	“The skills that I learned in clubs bleed into the skills that I need in order to succeed in my formal Alfaisal education.. I learned how to communicate effectively.” student
	“But we're here the competition level is really high you have something that's called Dean's List. So, no matter what everyone wants to be on it and feels capable of being on it … so that competition is there.” A student
Theme 4	Culture and Socialization
	“we are exposed to a different array of religion in people.. and yes I was.. if you were to ask me to argue with these people before I entered University yes I would have been like really harsh really.. like you know aggressive about it, but now my values remain the same.. I mean my thoughts on the matter is the same but the way to communicate with them as a result of learning to communicate in general will result in me being.. slightly more.. civil whilst communicating with them” A student
	“Alfaisal has people from different nationalities and different backgrounds both on student and faculty level, and I think interacting with different people from all over the world… this adds to you.” A student
	“The culture of the students is very diverse and despite these massive differences in culture… I believe that the academic environment in Alfaisal brings us together and gives us one common purpose and helps us remain focused and prevents any form of disunity from erupting. A student
	“The environment at Alfaisal.. the poster day they are.. having poster day in one of the weeks is actually you know.. they are implementing the fact that research is important and I did not realize that.. the.. the importance of research until I entered Alfaisal university. It really teaches you that research is an important tool in the development of any nation.” A student
	“The support they give for the clubs they allow us to work together so in a way they help us improve our social skills or team management skills.” Student quote
	“I feel like I've changed and became more diverse when I entered University compared to my high school years.” A student
	“I'm coming from a high school.. I'm the top 99 percentile or whatever.. I have this feeling that I'm the best and I don't need them.. going into university you get much more calm and you learn how to ask for help.. I think that's very valuable both in university life and clinically later on.” A student quote
	“I appreciate the time that I do spend with my family more than I used to.” A student
	“I think after studying medicine I'm even more passionate about that… I feel like just being in this environment surrounded by clinicians and people who share the same interest has developed this passion even more and more I'm even more reading research papers and taking part in that type of academic stuff just so I can be on the same level as them.” Student quote
Theme 5	Teaching Methodologies and Hidden Curriculum
	“Indirectly the TBL thing the whole thing about having to work with other people and teammates that does force you in situations where you have to be examined how you treat other people and that does change your values” Student quote
	“It gives the students chance to like… show off… and that's a good thing because it's going to motivate other students to be like them… and to motivate them to study. Personally, I see…like for instance I see this person who is … who is giving out answers in TBL or speaking out in PBLs or explaining the case in TBRs or giving out answers in TBRs and I inspire to be like that person and this motivates me to study.” Student quote
	“In TBLs.. we used to have this.. if you don't if you don't think that this answer should be accepted you make an appeal.. I think this is very very good because this teaches the student that yes if you think you're right you can raise your voice but you have to provide certain and.. certain and reliable evidence” Student quote
	“Sometimes I don’t feel it is implemented very well… TBR are implemented well enough to potentially force the behavioural outcomes we should expect out of them.” Student quote
	“As a system..we.. the learning is not very much tied up with the learning objectives.. it is now mainly based on the teaching faculty and that's why it is.. it it.. it varies from subject to subject discipline to discipline and discipline and for the students it becomes difficult sometimes.” Student quote
	“The main objective of PBL [problem-based learning] is.. the main is self-learning.. we want you to take.. take responsibility of your learning […] to some extent it is fulfilled but in large.. the concept is vanished.. because of the lack of training of faculty and training of the students more importantly.. students don't know what to expect from PBL … the second part is your communication with the peers and your faculty members and your seniors.. I think that part is working very well.. you learn how to communicate.. you learn how to respect others’ opinion.. and you know how to express your opinion” Student quote
Theme 6	Challenges and Student Support Systems
	“It is to large extent.. it is.. it is really student-centered and because.. as a faculty as an institution and we try to engage students in their own learning that is student-centered and it is working.” Faculty quote
	“Because we need an analytic analysis, we need to think out of the box and some of the students that are not used to it so they need a little bit of work.” Faculty
	“It's plus point as well because you have so many versatile.. versatile faculty from different areas so they can actually share their own experiences. … it's good for the.. for the growing and for the students as well.” Faculty
	“The mentorship.. the mentor program is really strong, especially the students are coming to their mentors and they're talking about it so definitely they're helping them.” Student quote
	“The other thing that I think Alfaisal has is that hidden you know motivation for students to do activities and to develop other skills outside you know the usual curriculum.” Student quote
	“It is to large extent.. it is.. it is really student-centered and because.. as a faculty as an institution and we try to engage students in their own learning that is student-centered and it is working.” Faculty

Funding

This research was not funded.

Availability of Data and Material

All data is anonymized and available for review with primary and corresponding authors.

Code Availability

Being a qualitative study, codes and themes are defined in the article.

Declarations

Ethics Approval

This study was approved by Alfaisal Institutional review board vide IRB approval number 18083.

Consent to Participate

All participants filled and gave signed consents before the interviews.

Consent for Publication

All authors have reviewed the final manuscript and given consent for publication.

Competing Interests

The authors declare that they have no conflict of interests.