Editor’s Note: This post is a response to Joshua Liao, Eric Thomas, and Sigall Bell’s essay, “Speaking Up About The Dangers Of The Hidden Curriculum,” published under Narrative Matters in the January issue of Health Affairs.

As the lights in the auditorium go down, just before I flick on my microphone, I remember what media critic Marshall McLuhan once said about culture: We live “in an electric information environment that is quite as imperceptible to us as water is to fish.”

As a leader of my institution’s curriculum redesign effort, I often speak with departments and even the whole faculty about our plans for the new curriculum. These experiences have made me acutely aware of how well McLuhan’s quote applies to what has been called the “hidden curriculum” in medical education. Medical education, and the culture of medicine in which it occurs, influence personal identity and perception so pervasively that it can be a challenge to talk clearly about how to change the hidden curriculum.

Liao and colleagues overcome that challenge in the January issue of Health Affairs, making an eloquent call for better dialogue about how the hidden curriculum can undermine patient safety. They point out, rightly, that, “The difference between what we say we do and what we actually do as doctors and teachers can be stark.” Such verbal disconnects can undermine the culture of patient safety, a dilemma fixed first through awareness and then through the courage to speak up.

There is no doubt we need a better culture of safety in medical education. In a survey of Iowa medical students, 32 percent reported inadequate communication to families, 19 percent saw patient confidentiality breached, and 14 percent witnessed deliberate deception in the context of medical care. A New York state study called out another likely universal problem: medical students fear reprisal if they report errors to protect patient safety.

Yet we can train students to prioritize patient safety. In a foundational study, Self et al showed that medical ethics training improved medical student moral reasoning, and a more recent study from Glasgow showed that a medical ethics curriculum changed medical student attitudes about ethical issues. Similar changes have been shown among health professions students who participated in a patient safety curriculum. However, changing attitudes do not always translate into changing behavior. For example, the same Glasgow researchers who showed that medical ethics training changed attitudes failed to show an impact on how the students plan to respond to a witnessed medical error.

This is not surprising. Culture change is difficult to create, and even harder to assess. Classroom teaching – which is easiest to control and assess – may be the weakest instrument of change in part because it can be undermined by countervailing messages in the hidden curriculum.

Liao et al thus argue persuasively for measures that stretch far beyond the classroom and into the clinical context. They suggest multiple interventions, from the creation of a safety-oriented institutional culture to public recognition for safety interventions. Though such interventions have yet to be linked to better patient safety outcomes, hopefully the proof will come from ongoing work, such as by the essay authors and Harvard University ethicist Lisa Lehmann, who also studies the link between moral courage and patient safety.

Amid such efforts, we must be mindful that there is more to culture change than talking about it, or even speaking up about medical error. Culture is constructed of words, undoubtedly, but the context in which those words occur is at least as important as the words themselves. We must remember, as McLuhan reminded us, the medium is the message. And the medium in medical education – from morning report to ward rounds and every committee meeting in between – is teamwork.

I have learned and relearned this lesson during our medical school curriculum redesign. Faithfully working through John Kotter’s 8 stages of institutional change, I have lovingly crafted talking points and PowerPoint slides to deliver in public forums. In large auditoria, and one-on-one with thought leaders, I have made my point, I have listened, and hoped to move change forward through that conversation. But more and more, I have come to believe that the words we speak about culture change mean less than changing the way we go about our day-to-day work.

In curriculum redesign, and other forms of culture change, the bulk of cultural change occurs not on stage but in the drab conference rooms where small groups meet to do the daily work that seems – at least on the surface – completely unrelated to culture change. We might be hammering out objectives for a new course or debating the distinctions between problem-based and case-based learning, and thus completely unaware that we are doing the heavy lifting of cultural change. But that’s exactly what we are doing. It all comes down to how we form teams.

If we structure teams inclusively and develop effective and accountable methods for achieving team goals then we create a healthy culture within that team. When that team succeeds, so does the rapport established between the group’s members, and this changes institutional culture, intentionally, incrementally, and in an interconnected way.

For instance, to improve cross-departmental coordination of teaching, we formed multidisciplinary collaborative course design teams charged with creating cross-disciplinary courses together. We put infectious diseases doctors in a room with microbiologists, virologists and immunologists, and asked them to design courses together instead of separately. Each team was required to seek feedback from multiple departmental stakeholders. We engaged champions of health care delivery science, bioethics and practice resilience to work as parts of our multidisciplinary course design teams. As a result, these important but previously marginalized topics have been woven into the core fabric of the medical school curriculum, and the way we pursue curriculum redesign has been shaped by input from these new team members. This has led not only to a better-integrated curriculum redesign plan, but also improved cross-departmental faculty relationships and even novel scholarly collaborations.

The importance of these newly formed teams cannot be over-emphasized. The curriculum we design today will be revised in the years to come, but those revisions will stay true to the original vision if the culture we create with our teams persists. If cross-departmental collaborations continue to thrive, students will continue to learn in an integrated curriculum. And these durable alliances lay the foundation of culture change to come.

Culture change like this takes time. We are far from done with this job at my institution. As curriculum redesign deadlines approach, and when uncertainty emerges, participants can fall back on bad habits like feeling overwhelmed or marginalized. Negativity bias can take hold, in which vivid fears of risk can overshadow equally important but habitually less compelling motivators of change. When these factors come into play, and inevitably they do, an organization’s leadership must remind participants of the core principles that drive their work, the team spirit responsible for successes to date, and to invoke a just and transparent process to shared goals.

That is why articles like “Speaking Up About the Dangers of the Hidden Curriculum” are so important: they help us reorient to where we are on the road to change. With Liao et al’s clear-eyed articulation of the need to improve the culture of medical education in part through moral courage close at hand, we must transition seamlessly to the heavy lifting of culture change. And that involves teamwork. Teamwork is the water in which we swim.