Purpose: The "hidden curriculum" has a powerful influence in shaping medical students' attitudes and behaviors toward patient care. The purpose of this project was to develop and test a tool (the C3 Instrument) to help educators characterize and understand the hidden curriculum at their own institutions. Method: In 2000, the authors developed survey items to measure three content areas of the hidden curriculum with respect to patient-centered care. These content areas include role modeling, students' patient-care experiences, and perceived support for students' own patient-centered behaviors. The survey was distributed to third- and fourth-year students at ten medical schools in the United States. Using factor analysis, the authors selected items for the final version of the C3 Instrument. To examine validity, they compared instrument scores to results of a poll of members of two organizations devoted to teaching patient-centered care. Results: A total of 890 students completed the survey. The mean age of students was 27 (SD 3). Fifty-two percent of students were women, and 70% were white. Twenty-nine items were selected for the C3 Instrument, with internal consistency measures ranging from .67 to .93 for instrument subdimensions. In the validation analysis, summary scores for all three content areas of the C3 Instrument were consistent with results of the poll of patient-centered organizations. Conclusion: Despite some issues that still need to be resolved, the C3 Instrument proved to be a reliable and valid tool that characterizes a medical school's hidden curriculum with respect to patient-centered care. It can be used to guide educational interventions by addressing the context that exists around formal teaching activities. It also makes possible the study of hidden curricula across multiple medical schools. Further research on the hidden curriculum should be aimed at developing a greater understanding of the dynamics between formal teaching activities and school culture.
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