A Hidden Curriculum
There is a version of medicine that most patients never see—the Hidden Curriculum.
It refers to the culture of medicine, the ways we’re taught to “act like a doctor” that go beyond anatomy or physiology.
The Hidden Curriculum teaches how we’re expected to carry ourselves, react (or not react) to our emotions, and the way we’re supposed to interact with others—including patients like you.
We learn this curriculum during our training years by working with more senior doctors and modeling their behavior. And although it’s not written in textbooks the Hidden Curriculum shapes how doctors think, how decisions are made, and whether patients feel heard or dismissed.
As patients come to their doctors not only with symptoms of long COVID, but questions powered by research and AI tools, the Hidden Curriculum is outdated.
In my recent Substack Live, I spoke with Zed Zha, MD (she/her) about this medical culture. She is the author of a new book, “Consented: A Doctor’s Call to End Medical Violence and Reclaim Patient Autonomy.”
Our conversation focused on a difficult but necessary question: if most physicians enter medicine with good intentions, why do so many patients leave feeling unheard, dismissed, or blamed?
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How medical training shapes behavior
One answer lies in how physicians are trained. Medical education does not simply teach information; it shapes identity. Over time, it reinforces habits that prioritize certainty, reward confidence, and discourage visible uncertainty.
Physicians learn quickly that not knowing is weakness, and projecting authority is rewarded.
In that environment, collaboration can feel like a threat to professional credibility.
This does not produce “bad doctors.” It produces clinicians who are adapting to the system they were trained in. Sadly, patients experience the downstream effects of that training in very real ways.
Why patients adapt to the system
Patients often find themselves adjusting their behavior in order to be taken seriously.
They may research extensively before appointments, carefully choose their words to avoid appearing confrontational, or try to present their symptoms in a way that fits what they believe a physician will accept.
As we discussed in the livestream, many patients are not only managing illness, but also managing the interaction itself in order to be believed.
“I have to be put together enough for my doctor to believe me. I have to look pathetic enough for my doctor to believe me. I have to be nice enough for them to listen to me. I have to be forceful enough for them to listen to me.”
—Dr Zeest Khan
The underlying issue: power
This dynamic reflects a deeper issue: medicine still operates within an outdated power structure.
Traditionally, the physician defines what is true, while the patient is expected to comply. Consent is often treated as a discrete event—a form signed before a procedure—rather than an ongoing process of communication and mutual understanding.
That’s an outdated approach.
Dr. Zha reframes this more accurately. Physicians bring medical training and clinical reasoning, but patients bring something equally essential: lived experience. As she put it, patients hold their own “bodily truth.” Without that, no diagnosis or treatment plan is complete.
“Patients hold their bodily truth. They’ve lived in their body for years. We’ve lived in their body zero days.
[Physicians] have been raised in this culture where we [hold] power over patients… and a lot of times we don’t even realize we’re doing it.” —Dr Zed Zha
What better care actually looks like
During the livestream, a reader made an important comment in the chat: the patient-doctor relationship should really shift to a partnership. I couldn’t agree more.
In practical terms, that shift looks like:
Patients being encouraged to share what they know, including research and lived experience
Physicians openly acknowledging uncertainty when it exists
Clinical decisions being discussed rather than dictated
Consent treated as an ongoing dialogue, not a one-time signature
This approach not only requires more time, but a total paradigm shift. That being said, it’s a shift that is very possible and very needed.
The strain on both sides
Making things harder is the fact that both sides are strained.
Physicians are working within systems defined by time pressure, productivity metrics, and administrative burden. Burnout and moral injury are real, and they affect how clinicians show up in patient encounters.
Burnout and moral injury increased exponentially during the first years of the pandemic, and most doctors haven’t been given time or resources to process that very real trauma.
Instead, the opposite has happened. Doctors feel like unappreciated cogs in a wheel.
“We’re working our butts off so that we can provide access… and meanwhile we’re getting burnt out by the machine that is this medical system.” —Dr Zed Zha
Patients, meanwhile, are navigating illness and often dismissal. When these two forms of strain meet, the result is often frustration, mistrust, and breakdown in communication.
Understanding this context doesn’t excuse harmful behavior, but it does clarify why it happens and where it could change.
What patient empowerment actually means
For patients, empowerment doesn’t mean confronting every physician or trying to “win” an appointment. It begins by understanding how the system works and what a reasonable standard of care should include.
Patients can tell when communication is collaborative versus dismissive. They already know that participation in decision-making is not inappropriate—it is essential.
Doctors have to catch up. This is not a problem that patients should have to solve. The onus is on doctors like me and Zed.
Where change begins
For clinicians, the shift begins with small but meaningful changes: by listening and viewing patients as partners rather than problems to solve.
My conversation with Dr Zha is not abstract. It reflects a growing divide between patients and physicians—we’re really struggling to understand one another.
This is also a trust issue.
Rebuilding trust requires acknowledging the structural and cultural factors that shaped it in the first place.
If you have ever felt dismissed, uncertain, or unsure how to navigate a medical interaction, this conversation will likely resonate. It is one of the more direct discussions I have had about the realities of medical culture and what needs to change.
Thank you to Zed Zha, MD (she/her) for joining me. You can learn more about Dr Zha and her work at her Substack, “Ask the Patient.”
What have been your most memorable interactions with a doctor, good or bad?
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