Providing a model of a hidden curriculum in medical majors with an emphasis on medical ethics

Introduction Universities of medical sciences are one of the most important centers and institutions that train young and specialized people at the level of higher education and has an important mission. Moreover, the relationship between a university of medical sciences and the health of the individuals and society, as well as the entire service and treatment system, are the core of medical higher education.1 Due to the importance of medical education, its curriculum should be properly designed and implemented, and in addition to the formal and designated curriculum for students, the “hidden” curriculum, or that part of the curriculum that consists of unspoken or implicit academic, social, and cultural messages, should also be addressed. This hidden curriculum is one of the most important tools and elements to achieve the general goals and missions of medical education. Along with formal education, the hidden curriculum conveys values, ethical and professional principles to medical students, and make medical ethics important for them.2 Because the hidden curriculum is an unpredictable dimension of learning, if this dimension is not considered in educational design, it neglects an important part of the factors that have a great impact on learning. Usually in educational design, obvious factors are considered and hidden factors are omitted. Therefore, it is helpful to identify factors related to the hidden curriculum and attempt to control them to some extent in designing and implementation.3 Medical ethics is the observance of principles and values in medical decisions that should be involved in

any decision related to the health of individuals or society. The subject of ethics is an important issue that the hidden curriculum can affect in the medical system and is a means to guiding medical students towards becoming more ideal and professional. 4 The role of the hidden curriculum is not only shaping what doctors have learned but also changing a physician's behavior and ethics and ways in which a physician can succeed in the healthcare system. Physicians confront new experiences in clinical skills that can create a gap between reality and practice. 5 The hidden curriculum, which has been considered important during the study period along with formal education and has been able to influence students' attitudes and behaviors, may help the physician reduce the gap between ideal and existing performance. 6 The role of the hidden curriculum, meanwhile, is not only to shape what physicians have learned, but also to conceptually change the idea and thought of how a physician succeeds in the health care system and, of course, the formation of medical ethics. 7 Rogers et al, 8 conducted a study, "Using a hidden curriculum in professional training, " in the surgical department at the University of Southern Illinois among 134 medical students of a two-year surgical training course. They examined medical students' views on medical ethics. The results showed the ethics of medical students are influenced by the hidden curriculum and that the formal and hidden curricula in each permanent medical training course can analyze and support the connections between physician and patient, as well as interactions between the physician and the health care system. Macleod 9 conducted research entitled "Hidden curriculum, ethics and profession", which sought to improve the clinical learning environment of students in becoming physicians. The current training course for medical students is mostly related to behaviors and characteristics that are contrary to the field of medical and professional ethics. These negative points are in direct conflict with the lesson, patient expectations, the community, and medical educators. These issues lie in the organizational structure and culture, and that part of the curriculum hidden in medical faculties and hospitals.
Although the connection between the hidden curriculum and medical ethics is theoretically clear, experimental research on such a relationship has not been directly conducted. 10 As a result, due to a lack of comprehensive research in this field, it is helpful to create a context for more comprehensive and numerous studies in this field. Therefore, the current study aims to provide an empirical study model of the hidden curriculum and medical ethics.

Material and Methods
The study population consisted of all professors and fourth-year medical students at the University of Tabriz in the academic year 2019-2020. The criterion for selecting these students was that before entering clinical internships and only with theoretical training, they have no experience in direct observations in medical centers and thus cannot express what they have not experienced. Therefore, many tried to make the students even higher than the fourth and fifth year. The samples were selected due to their more detailed study and also multiplicity of information using a purposeful sampling approach and the snowball method. Those who were selected as interviewers introduced other people who had comprehensive information about the subject. The number of professors was 11 and the number of students was 25 for a total of 36 people who entered the study. The interview information from 22 students and 8 professors was duplicated and the data became saturated at this stage, but the interview process continued to 36 interviewees to assure confidence. Interviews with professors and students were conducted in the form of in-depth semi-structured interviews individually by the researcher to further explore their views on the subject of research to fulfill all the factors and conditions of a good interview and to make the most of the experiences of professors and students. This method of data collection provided the opportunity to review and discover the diverse experiences of professors and students in the field under study. Then, the content of the interview data was analyzed based on the research question. The interview process took 30 to 60 minutes. With the permission of the participants and with an assurance of confidentiality, in order to increase the quality and accuracy of the interview data, the interview was recorded using digital tools. During the interview, certain codes were used instead of names to assure confidentiality in the research. The accuracy and quality of the current study was internal, which indicates the degree of data stability. Data analysis was performed by the two authors of the article and then the data and their interpretation were provided to interview participants to confirm the quality and accuracy and to inform interpretation. To increase data stability, interviews were conducted in a suitable atmosphere and observing the interview conditions with the appropriate instructions, away from bias and personal opinion, and using a tape recorder. Simultaneously with data collection, analysis began with the twin objectives of obtaining feedback for subsequent interviews and ensuring data saturation. Data analysis was performed according to Smith's proposed method 11 for the qualitative part. Smith proposed three steps for analyzing data in the phenomenological method: a. Data production; b. Data analysis (this step includes sub-steps: 1. Initial confrontation; reading and re-reading an item, 2. Identifying and labeling categories, 3 Listing and clustering categories, 4. Creating a summary table ); and c. Combining items. 12 To analyze the collected data, interviews were transcribed word for word by the interviewer after each interview to form the analysis unit. After determining important phrases and words, these were identified as codes, and similar codes were then merged and initial classification was performed.
From the very first interviews, codes and subclasses were identified, and the data degradation process continued in all codes until classes emerged. To validate the research, people with suitable knowledge and information were included in the study. Therefore, the minimum criteria for entering the interview were experienced people with suitable and fruitful experience. To achieve transferability, the researcher must present his data set and textual descriptions completely and richly so they can be adapted to previous theoretical literature and receive theoretical confirmation of the findings. Simultaneously, other researchers should be able to judge the transferability of such findings to other environments. The information obtained by seven faculty members who are specialists in the field of qualitative research, three of whom are professors at the Tabriz Medical School, was placed as Delphi and group techniques, and in different stages of the Smith method, used as a group, and the information then reviewed and approved. In addition to describing the study area, the necessary explanations about the participants and their direct quotes were also provided. To determine reliability, two people familiar with the qualitative research method coded the interviews separately to examine the agreement between their opinions. Extreme care was taken in collecting, implementing, and recording data and allocating sufficient time to collect data. The data, interpretations, and findings of this study were verified several times through careful review and revision; this process was followed through review of previous studies, so other researchers can understand the experience of experts in this field and follow the data and achieve similar results. Descriptive, analytical, interpretive, and inferential methods were used to analyze the data obtained from documentary studies. In this research, both inductive and deductive methods were used; inductive and partial were used for interviews and obtaining information and experiences. At the same time, by analogy, the hidden curriculum models and questionnaires were examined and the main dimensions and components were identified and separated, and then the secondary themes were placed in a framework and were adapted to the models inductively and deductively.

Results
After studying the content of the interviews and the mentioned topics, creating the initial classifications and clustering according to Smith method, the subcategories and main themes are identified in Table 1.

Objectives and Curriculum
Non-specialized / non-applied education and teaching: One of the most important factors in objectives and curriculum in medicine is "applied and specialized teaching methods". Most interviewees mentioned many problems of this type as the main cases in the applied teaching method taking into consideration the theoretical teaching of the professor and the lack of knowledge transfer to the students during the patient's visit.
Weakness in objective setting and curriculum development: One of the most important factors in the hidden curriculum objectives in medicine is "curriculum objectives". Most interviewees identified attention to medical science education without regard to human and moral issues, lack of attention to the patient and mere attention to the disease itself, and lack of education to students about altruism with the patient as the main issues in the hidden curriculum goals.

Physical space
Inadequate physical space: Inadequate educational design and architecture, insufficient educational space, low attention to the welfare and safety of students, were among the items expressed by the interviewees as important, noted as influential yet forgotten factors concerning the geophysics of the faculty and the hospital.

Backgrounds and perspectives
Bad personal/family/environmental background: It seems that the adverse effect of the student's family / social environment and the adverse effect of personal factors and the student's school background are among the most important factors in determining students' views on medicine.

Laws and regulations
Ignoring patient rights: One of the most important factors in paying attention to ethics in the hidden curriculum in medical disciplines is "failure to maintain professional ethics towards the patient. " Most of the interviewees identified lack of respect for privacy and the rights of the patient, lack of permission from the patient for examination, lack of confidentiality concerning the patient, examination of the patient in public, and non-observance of patient privacy in public as primary examples of noncompliance with professional ethics. Patients themselves were described as "hidden" in the curriculum.

Relationships
Immoral and inappropriate behavior: One of the most important factors of relationships in the hidden curriculum in medicine is "professors' relations with  Lack of the sense of responsibility of students in the assigned affairs students". Most of the interviewees noted humiliating and discriminatory attitudes towards the students, pride of professors, and lack of proper attention and training to the general practitioner as the principal issues in the relationship between professors and students in the hidden curriculum.
Of course, one of the most important factors in the hidden curriculum in medicine is "professors' relationships with medical staff, students and patients. " Most interviewees noted poor behavior of professors with nurses led to bad behavior of nurses towards students, along with failure to introduce professors and physicians to the patient, lack of attention to gaining the patient's trust by the physician, and lack of responsiveness to the patient and his companion. Students and patients were together were described as "hidden" in the curriculum.
And finally, one of the factors of relationships in the hidden curriculum in medicine is "treatment staff relations with patients". Most of the interviewees mentioned knowing the person from his / her illness and not from his / her identity and a poor tone or harsh tone of treatment staff towards the patient as the most important issues in the relationship between the treatment staff and patients in the hidden curriculum.

Discussion
The current article aims to identify the dimensions of the hidden curriculum in medical trends by emphasizing medical ethics and presenting an experimental study model of the hidden curriculum and medical ethics at the Tabriz University of Medical Sciences. Our findings showed that the main dimensions of the hidden curriculum with an emphasis on medical ethics resulted in identification of five factors: objectives and curriculum, physical space, backgrounds and perspectives, laws and regulations, and relationships. Given that physicians have the most sensitive job in human society, medical ethics are of paramount importance. Accordingly, paying attention to the ethical characteristics of this job plays an important role in the process of treating patients. However, in university courses and formal medical education curricula, the emphasis is on scientific and specialized courses about disease along with the process of treatment and control of the disease. Attention to the patient is often not taught in medical texts, and appropriate behaviors of physicians and medical staff are generally omitted. Therefore, the hidden curriculum plays a vital role in resolving these shortcomings in formal medical education curricula. Paying attention to hidden goals and the hidden curriculum can be a crucial factor in promoting medical ethics among today's students and tomorrow's doctors. In terms of objectives and curriculum, the findings of the present study are consistent with other results. 2,5,[13][14][15] In this regard, 2,5,13-15 it has been shown that it is very important to pay attention to ethical issues and patient communication education, including goals and curricula in medical disciplines, but the level of compliance is not optimal. Therefore, to improve students' medical ethics, it is necessary to include certain items in the curriculum. In addition, due to teachers' experiences of the hidden curriculum, more attention will be needed from professors, educators, and educational administrators. In addition, educational and workshop programs are needed to be able to explain the important role of professors in shaping student behavior. In the field of physical space, the results of this research are in line with studies 16,17,18 that show that compliance with the necessary standards in the design and construction of physical space and medical schools increases students' morale and happiness, which can directly teach, motivate and influence them. Of course, no matter how ideal a college's physical space is, if it lacks suitable professors and staff, this also causes frustration and weakens student morale and interest. The impact of environmental and family conditions is so important that it can be seen in this study. The results of other studies 19,20,21 are consistent with this study and show the most important factors in the formation of ethics, attitude and behavior of medical students. Consistent with other results, 19,20,21 in this study, teaching students how to deal with patients is important in addition to specialized knowledge and skills in the field of science. Thus ideal medical education seeks to develop and reinforce values, attitudes, ethical norms, social skills, and other characteristics that shape a physician's behavior or professional skills. According to medical education experts, the hidden curriculum is the strongest way to transmit medical values. As a result, paying attention to ethics may be as effective as providing specialized training to students in treating patients. In addition, other research 22,23 has shown that the following conditions can lead to students' self-esteem and appropriate education: two-way relationships between faculty and students, medical staff and patients, medical staff with students and patients, students and patients; ability to communicate appropriately with medical ethics; no discrimination in teacher's behavior towards students; no contempt on the teacher's part towards students among patients; and respect for students and medical staff by professors is consistent with the findings. The results of other studies 24,25 have shown that students' communication skills are directly related to patient-centered curriculum, and communication skills play an important role in learning medical ethics and professional behavior. Therefore, it is necessary for students to acquire these skills in patientcentered care, to respect cultural diversity, and to take on responsibilities needed to serve the patient. In addition, medical staff can assist in the process of patient recovery without any bias towards students while providing services to patients and cooperating with students in this field.

Conclusion
According to the findings, medical ethics can be viewed based on the role of goals and curriculum, physical space, attention to contexts and perspectives, rules and regulations, and relationships. In this study, students' experiences of medicine and medical ethics were studied and categorized and a model was developed based on the identified dimensions of the medical curriculum. Future researchers in this field can use the model of this study to study the involvement of the hidden medical ethics curriculum along with the hidden items of the medical ethics curriculum. The designers of medical ethics questionnaires and the hidden program of medical ethics can design structures and dimensions of their questionnaires from the dimensions and themes identified in this study. Extractive dimensions are neutrally adapted and studied by studying and applying the hidden curriculum model. 26 For practicing medicine in medical centers, it is suggested that university textbook planners in the field of medicine should pay more attention to effective aspects of medical ethics to increase its importance and make it clearer for students to improve the course of patients' disease. In addition, due to major experiences in such ethical cases in dealing with patients, in addition to specialized and scientific training, professors should include ethical and specialized cases in the content of their curriculum. Another suggestion is that medical center officials and university officials should monitor the behavior of professors and physicians towards medical staff, students and patients to establish good relations between professors, medical staff and students.

Ethical Approval
All participants of the study were requested to fill out a consent form and the researchers assured them that the research results would be confidential. This research is taken from the student of Islamic Azad University, Tabriz Branch, and has received ethics approval with the number IR.IAU.TABRIZ.REC.1398.094.