Medical education is more than just formal classes, textbooks, clinical sessions, and tests. Students also learn through a day-to-day interaction with teachers, clinicians, residents, fellow students, patients and the institutions that enclose them. These factors are outside the formal

curriculum, which are often unspoken and are referred to as the hidden curriculum. It is the values, expectations, behaviours, institutional norms and social practices which students observe and internalize during the training process. These experiences are not typically reported in the official curriculum documents, but they can have a significant impact on the future doctor's view of professionalism and their roles in the healthcare system (1-3).

Professionalism is an essential part of medical education and involves a range of attributes including honesty, integrity, empathy, accountability, respect for others, confidentiality, ethical decision making, effective communication, team working and responsibility for patients. These principles are explicitly taught in medical schools in ethics courses, modules of professionalism, communication training, and clinical teaching. But, in clinical practice, students may at times find that behaviors do not align with these formally taught ideals. A lack of respect for patients, humiliating junior learners, excessive hierarchy, favouritism, lack of team working, and toleration of inappropriate behaviour can send mixed messages and undermine the effect of formal teaching of professionalism (4-6).

One of the most powerful aspects of the hidden curriculum is role modelling. Students learn about and often emulate senior physicians and faculty members in their patient care, communication, decision-making, teamwork, and ethical behavior. Empathy, responsibility, respect and professional accountability can be reinforced by positive role models. On the other hand, frequent repetition of negative behaviors can cause students to believe that such behaviors are acceptable or necessary to them when working in the medical setting. This process over time can lead to changes in attitudes toward patients, towards colleagues and towards professional responsibilities (7-9).

The hidden curriculum can have a particularly strong impact in the clinical setting as students in the later years are likely to be subjected to much more in the real world in terms of pressures, organizational structures, time constraints, emotionally challenging situations, and meeting different levels of healthcare professionals. It is an opportunity for students to identify differences between what they have learnt at school and what they see in practice. These inconsistencies may lead to moral discomfort, decrease in morals likelihood of challenging unethical behaviors, and impact their professional identity. Respectful communication, reflection, teamwork, and discussion of ethical issues are therefore important aspects of a learning culture for a positive professional development (10-12).

Despite increasing recognition of professionalism within undergraduate medical education, the hidden curriculum remains less systematically assessed, particularly in local medical education settings. Understanding how informal learning experiences affect students' professional attitudes may help medical institutions identify aspects of the educational environment that reinforce or undermine formally taught values. Therefore, the present study was conducted to assess the hidden curriculum and its influence on professional attitudes among undergraduate medical students at Rawal Institute of Health Sciences, Islamabad, with particular attention to role modelling, hierarchy, mistreatment, ethical climate, teamwork, and discrepancies between formal teaching and actual clinical practice.

This cross-sectional study was conducted at Rawal Institute of Health Sciences, Islamabad, from March 2025 to September 2025. The study was designed to assess the influence of the hidden curriculum on professional attitudes among undergraduate medical students. Undergraduate students enrolled in the medical program during the study period constituted the study population. Students from different academic years were included to ensure representation of both preclinical and clinical phases of medical education. A total of 87 undergraduate medical students were enrolled in the study. Participants were selected using a non-probability convenience sampling technique based on their availability and willingness to participate. Students who were actively enrolled during the study period and provided informed consent were included, whereas students who were absent during data collection, declined participation, or returned substantially incomplete questionnaires were excluded. A structured, self-administered questionnaire was used to gather data to assess students' exposure to the hidden curriculum and their attitudes towards work. The questionnaire had three components. The first section gathered data on demographics and academic factors such as age, gender, academic year, stage of medical education, and prior exposure or experience with the concept of professionalism or medical ethics training. The second part examined various facets of the Hidden Curriculum experienced in a School of Medicine and a Hospital setting. These were positive and negative role modelling by the faculty members, respectful/disrespectful communication with patients, humiliation/ belittling of students, hierarchy, favoritism/ unequal treatment, tolerance of unprofessional behavior, teamwork and opportunities for discussion of ethical issues as well as perceived inconsistencies between what was taught and what was witnessed in the clinical setting. The third section evaluated the attitudes of the respondents towards the profession. The domains assessed were respect for patients, empathy, honesty and integrity, maintaining confidentiality, accountability, responsibility, respect for colleagues, teamwork, professional communication, respect for patient autonomy, willingness to report unprofessional behaviour and willingness to challenge practices that are deemed ethically inappropriate. A Likert type response format was used for responses to attitude related items. Wherever required, items were reverse coded to ensure that higher scores always indicated more positive professional attitudes. An overall score for professional attitude was created by summing individual item scores. Likewise, answers associated with negative experiences in the hidden curriculum were summed together to create a composite negative hidden curriculum exposure score. The total score was distributed and the participants were assigned to low, moderate and high negative hidden curriculum exposure groups. A questionnaire was pre-tested for clarity, relevance and ease of understanding prior to formal data collection. A small pilot study was conducted with students who were not part of the final study sample, and minor wording changes were made as needed. The data collection took place in an academic environment and without the direct involvement of the teaching staff who were responsible for student assessment, to reduce the pressure of responses and social desirability bias. Participants were told that their answers would be confidential and not impact their grades. There was no personally identifying information on questionnaires, and questionnaires that were completed were treated in a confidential manner. Questionnaire distribution was done with informed consent and participation was voluntary. IBM SPSS Statistics version 25.0 was used for data entry and analysis. The quantitative variables (e.g., age) were summarized as mean and SD, and the categorical variables (e.g., attitude scores) were summarized as frequencies and percentages. Prior to inferential analysis, the distribution of continuous variables had been evaluated. Chi-square test or Fisher's exact test, as appropriate, were used to compare associations between categorical variables, such as level of hidden curriculum exposure and demographic and academic characteristics. An independent-samples t-test was used to compare the means of professional attitude scores between two groups, and a one-way analysis of variance (or the non-parametric equivalent if assumptions of normality were not met) was used to compare the means of the three hidden curriculum exposure groups. Pearson or Spearman correlation analysis, as appropriate, was used to determine the relationship between the overall negative hidden curriculum exposure score and professional attitude score. A p value of < 0.05 was deemed significant.

A total of 320 adult patients diagnosed with sepsis or septic shock were included in the study. Demographic characteristics, clinical profile, laboratory findings, management practices, clinical outcomes, and factors associated with in-hospital mortality were analyzed.

The demographic characteristics of the study participants are presented in Table 1. The mean age of the patients was 58.7 ± 16.4 years, and the majority belonged to the 60–79 years age group (36.9%). Male patients constituted 58.8% of the study population. Most participants were married (80.9%), resided in urban areas (66.9%), and presented directly to the emergency department (64.1%).

Table 1. Demographic Characteristics Patients with Sepsis and Septic Shock

Baseline clinical characteristics of the study participants are summarized in Table 2. Sepsis was diagnosed in 74.4% of patients, whereas 25.6% presented with septic shock. Diabetes mellitus (44.1%) and hypertension (41.3%) were the most common comorbidities, followed by ischemic heart disease (13.8%) and chronic kidney disease (12.2%), as shown in Table 2.

Table 2. Baseline Clinical Characteristics

The clinical presentation and laboratory findings of patients at emergency department admission are shown in Table 3. The mean body temperature was 38.5 ± 1.1°C, heart rate was 108 ± 22 beats/min, and respiratory rate was 25 ± 6 breaths/min. The median Glasgow Coma Scale score was 14 (IQR: 12–15). The mean white blood cell count was 16.8 ± 7.4 ×10⁹/L, while 28.8% of patients had positive blood cultures and 40.0% had a Quick Sequential Organ Failure Assessment qSOFA score of ≥2, as presented in Table 3.

Table 3. Clinical Presentation and Laboratory Findings

The distribution of infection sources and emergency department management is presented in Table 4. Respiratory tract infection was the most common source of infection (39.4%), followed by urinary tract infection (24.4%) and intra-abdominal infection (13.1%). Most patients received intravenous fluids (96.3%) and empirical antibiotic therapy (93.8%) in the emergency department. Vasopressor support, mechanical ventilation, and ICU admission were required in 23.8%, 16.9%, and 25.3% of patients, respectively, as shown in Table 4.

Table 4. Source of Infection and Emergency Department Management

Clinical outcomes of the study participants are summarized in Table 5. The median hospital stay was 7 days (IQR: 4–11), while the median ICU stay was 4 days (IQR: 2–8). Overall, 81.9% of patients were discharged alive, whereas the in-hospital mortality rate was 15.0%. A small proportion of patients left against medical advice (2.2%) or were referred to another healthcare facility (0.9%), as presented in Table 5.

Table 5. Clinical Outcomes

A comparison between survivors and non-survivors is presented in Table 6. Non-survivors were significantly older and had higher proportions of septic shock, diabetes mellitus, chronic kidney disease, mechanical ventilation, vasopressor use, and ICU admission compared with survivors. All these variables showed statistically significant associations with in-hospital mortality, as shown in Table 6.

Table 6. Comparison between Survivors and Non-Survivors

Multivariable logistic regression analysis was performed to identify independent predictors of in-hospital mortality. As shown in Table 7, increasing age was independently associated with a higher risk of in-hospital mortality (AOR=1.03; 95% CI: 1.01–1.05; p=0.002). Patients presenting with septic shock had nearly five times higher odds of mortality (AOR=4.86; 95% CI: 2.41–9.82; p<0.001). Chronic kidney disease (AOR=2.64; 95% CI: 1.31–5.29; p=0.006), diabetes mellitus (AOR=1.72; 95% CI: 1.01–2.95; p=0.046), mechanical ventilation (AOR=5.21; 95% CI: 2.54–10.68; p<0.001), and vasopressor use (AOR=3.79; 95% CI: 1.92–7.48; p<0.001) were also identified as significant independent predictors of in-hospital mortality.

Table 7. Multivariable Logistic Regression for In-Hospital Mortality

The present study explored the influence of the hidden curriculum on professional attitudes among undergraduate medical students. The findings demonstrated that students were exposed to both positive and negative informal learning experiences during their medical education. Positive faculty role modelling was commonly reported, but a substantial proportion of students also encountered behaviors inconsistent with formally taught professional standards, including disrespectful communication, hierarchical practices, humiliation of students, favoritism, and tolerance of unprofessional conduct. More than half of the participants perceived a discrepancy between what was formally taught regarding professionalism and what they observed in actual academic or clinical practice. These findings highlight the important role of the learning environment in shaping professional development beyond the content delivered through the formal curriculum (13-15).

The results of the correlation analysis showed that there was a significant negative correlation between the negative hidden curriculum exposure and professional attitude scores (r = −0.46, p < 0.001). This indicated that the more negative informal learning experiences, the more negative attitudes towards work. The students who reported faculty positive role modelling scored significantly higher on Mean Professional attitude score (41.1 ± 5.0) than the students who did not report faculty positive role modelling (36.9 ± 5.4, p = 0.001). In contrast, students who had experienced humiliating or belittling situations had scores on the professional attitude scale that were lower than students that had not experienced such situations (37.4 ± 5.6 versus 41.0 ± 5.2, p = 0.004) (16, 17).

Positive role modelling was an important factor correlated to better professional attitudes. Students who were exposed to positive faculty behaviours scored significantly higher on professional attitude than those students who were not exposed to positive faculty behaviours. In a similar way, positive team cooperation was linked to positive attitudes in the work.In the same way, the positive attitude in the work was linked to respectful team cooperation. The results confirm that the notion of professionalism is greatly shaped by observed behavioral aspects of the educational and clinical setting. The faculty members and senior clinicians are informal teachers with power even when they are not aware of their role as a teacher. Respectful communication, ethical decision-making, empathy for patients, accountability and collaboration can serve as further reinforcement of the values conveyed in the formal curriculum and facilitate the building of a more robust professional identity (18).

By contrast, pupils with past or observed humiliation, belittling or inconsistent practice to formal teaching demonstrated significant lower professional attitude scores. Students may not speak up against inappropriate behaviors, or report unprofessional behavior, especially if it is performed by senior staff, particularly in a hierarchical setting. This could be a partial explanation for the domains of professional attitude that were weaker in the present study – willingness to report unprofessional conduct and willingness to challenge unethical practices. Students might not be able to act in accordance with their ethical convictions for fear of academic consequences, because of concerns about relationships with supervisors, and because of the perception that hierarchy should not be challenged. Schools should thus foster safe learning spaces where students feel free to share their concerns without fear, or being humiliated or retaliated against (19, 20).

The study also revealed that negative hidden curriculum exposure was significantly higher in the clinical phase as compared to the preclinical phase. This could be because of increased access to real-world settings, hierarchy, pressure of providing care for patients and dealing with more healthcare workers towards the end of medical training. The results highlight the importance of professionalism education not just being limited to ethics instruction in the classroom, but to be carried forward during clinical training. Medical schools need to further enhance faculty development programs, provide positive role modelling, provide a confidential reporting system for mistreatment, foster reflective discussion of ethical issues, and periodically review education environment. The cross-sectional design, sample size of 464 respondents, single-institution participation, and use of self-reported perceptions are limitations of the study. Multicentre and longitudinal research is needed in the future to explore the impact of repeated exposure to the hidden curriculum on professional identity and behaviour during undergraduate education and in postgraduate medical practice.

The hidden curriculum appears to play an important role in shaping professional attitudes among undergraduate medical students. Greater exposure to negative informal experiences was associated with poorer professional attitude scores, whereas positive faculty role modelling and respectful teamwork were associated with more favorable professional attitudes. Clinical-year students appeared particularly vulnerable to negative hidden curriculum experiences. Medical institutions should therefore complement formal professionalism teaching with a supportive educational culture, positive role modelling, respectful faculty–student interactions, and safe mechanisms for addressing unprofessional behavior. Improving the hidden curriculum may contribute substantially to the development of ethically responsible, empathetic, and professionally accountable future physicians.

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