Psychological safety, the hidden curriculum, and ambiguity in medicine

Psychological safety is a feeling that individuals are comfortable expressing and being themselves, as well as comfortable sharing concerns and mistakes without fear of embarrassment, shame, ridicule, or retribution. It has long been recognized as part of successful patient safety and quality improvement processes. However, in the realm of medical education, psychological safety is a relatively unknown concept to many educators and learners alike. Learners, whether students or postgraduate trainees, are in a phase of cognitive apprenticeship whereby they learn not only skills and knowledge from teachers as part of an explicit and formal curriculum. At the same time, a hidden curriculum is also part of the learning environment in the form of norms, values, and behaviors exhibited by teachers. These norms, values, and behaviors become part of the culture of the clinical learning environment. The vulnerability of learners in this environment is magnified by the hierarchal nature of medicine, and the complexity, uncertainty, and the ambiguity inherent to medical conditions. This is especially true of cognitive specialties such as rheumatology. Educators who engage in unprofessional behaviors that result in learner humiliation and shame may serve to dampen productive discourse and scientific dialog. Therefore, educators must embrace psychological safety to foster learning and facilitate high-performing teams in the clinical learning environment.Key Points• Psychological safety improves communication and teamwork by allowing individuals to be comfortable expressing and being themselves, as well as comfortable sharing concerns and mistakes without fear of embarrassment, shame, ridicule, or retribution.• Commonly studied in the context of patient safety and quality improvement, psychological safety should extend towards medical education particularly in the context of allowing medical students and postgraduate trainees to be able to voice clinical reasoning in the face of ambiguity.• Educators take on a leadership role when having learners under their supervision; as leaders, educators are the prime movers of psychological safety• Learners in the process of developing their self-identity in the context of their chosen profession adopt not only knowledge and skills within the framework of an explicit and formal curriculum but also norms and values from daily behavior and language educators present in the clinical learning environment of learners; these norms and values are collectively part of the hidden curriculum.