Spirituality in Medical Education: Formal or Hidden Curriculum?

Medical education, beyond the acquisition of a set of knowledge and skills, is a quite complicated process of cultivation, formation, and development of health professionals (1) in the educational context which in turn, is deeply associated and intertwined with health delivery system. This is an output of close relationship and long-term interaction of the learner with the educational environment. The optimum output of this system, will be a graduate, possessing the required competencies and capable of performance with a holistic approach, a part of which are spiritual competencies (2). Regarding the significance of spirituality in holistic approach to health, medical education institutes and their accrediting agencies all over the world have seriously addressed the issue as an inseparable part of instructional goals and programs (3). Although this, by nature, is based on an old and original need, it is a relatively new phenomenon in formal medical education and thus undergoing a process of trial and error. Considering the multiple teaching and learning strategies and methods in medical education (4), the question arises about the best way for spirituality to be taught in medical schools.Determining the appropriate educational strategies in this field depends on a clear explanation of the aims and purposes of addressing spirituality in medical education. These aims could be classified in different levels, the minimum level being an overall perception of non-physical dimensions of human being. Nevertheless, the ultimate goal of incorporating spirituality in medical education according to the authors can be stated as a shift from the narrow biomedical paradigm to a deepened and strengthened holistic view among the health care potential workers, with special attention to Spirit as a truth composing a main part of his existence. It is believed that this recognition, followed by a comprehensive understanding of man and his diverse needs, leads to improvement in healthcare system and transcendence of health in human communities. In this way, addressing spirituality in medical education should be regarded paradigmatically, influencing many fundamentals of knowledge, attitude, and behavior. In other words, spirituality should be covered in medical curricula to convey a thorough knowledge of human being (5). It should be noted that during medical education, apart from technical knowledge and skills, a set of character traits and a kind of professional identity are formed, not only as a result of textbooks and educational materials, but through implicit and indirect messages conveyed within the atmosphere of education. These messages mainly focus on cultural customs, values, norms, social and behavioral expectations and tendencies, encompassing the concept of hidden curriculum in which, in addition to the content of the message, the sender, the environment and the way the message is exchanged are of particular importance (6). Hidden curriculum provides a capacity for transmission of messages beyond curriculum, which can be means of better training and finally better performance. Hidden curriculum, influenced by the organizational culture and especially role models, may be contrary to formal curriculum and the explicit educational goals. This is especially significant in clinical stages of medical education in which the actions of professors and others whose behavior is accepted as reference, accompanied by the overall atmosphere of the educational settings play a major role.It seems that to teach spirituality with the above-mentioned goals, it is necessary to take advantage from the capacity of hidden curriculum (7). Firstly, because it can be helpful in preventing against the negative consequences of what is implicitly taught in educational contexts, and secondly, to prepare the ground for utilizing it to develop and strengthen these competencies and meet existing challenges in areas such as medical ethics, professionalism, social accountability, and integrity. So, despite acknowledging spirituality and especially spiritual care as a part of formal curriculum, it seems that the effect of hidden curriculum is clearly greater on this dimension of health compared with other aspects of health. Although hidden curriculum exerts its effects in an implicit and at times unintended manner, targeted and planned interventions can lead to desirable effect on the learners. So it is recommended to consider spirituality in different levels from policy-making to planning, implementation and evaluation.