Shedding Light on the Hidden Curriculum: A Systematic Review of Ethics Education during General Surgery and Subspecialty Training

INTRODUCTION: Ethics education in surgical residen-cies is often delivered in an informal and nonstructured manner as part of a "hidden curriculum", leading to few residencies routinely including it in their core curricu-lum. This systematic review aimed to summarize the delivery modes, curriculum, structure, and effectiveness of ethics educational interventions for surgical trainees. METHODS: We performed a comprehensive database search including MEDLINE, Embase, Scopus and CEN-TRAL to search for articles describing the implementa-tion of ethics educational interventions for general surgery or subspecialty trainees. RESULTS: A total of 14 studies were included. Only 2 centers performed targeted needs assessment. Curricula covered included informed consent, the doctor-patient relationship, breaking bad news, decision-making, end -of-life care, conflicts of interest, considering patients' personal contexts, and surgical research ethics. Modes of delivery varied across studies, including case-based learning, group discussions, didactic lectures, reading material, role-playing, simulated patients, and ethics morbidity and mortality (M & M) meetings.Evaluations were most commonly via surveys exploring knowledge and self-reported confidence, with only 3 studies measuring actual trainee performance using objective structured clinical examinations. In general, the educational interventions increased trainees' confidence/preparedness in handling ethical dilemmas. CONCLUSION: We recommend comprehensive local needs assessment to guide curricular development and designing specific learning objectives and measurable milestones to ensure evaluation. Educational interven-tions are best delivered in a graduated manner with the complexity of the topic mirroring residents' real-life clin-ical responsibilities and experiences. Teaching modali-ties should be tailored according to the nature of the curricular content being taught to make the learning experience more interactive and effective. ( J Surg Ed 80:1075-1088. & COPY; 2023 Association of Program Direc-tors in Surgery. Published by Elsevier Inc. All rights reserved.)