title: The effect of the hidden curriculum on resident burnout and cynicism.
abstract: BACKGROUND
  Residents learn and participate in care within hospital cultures that 5 tolerate unprofessional conduct and cynical attitudes, labeled the "hidden curriculum." We hypothesized that this hidden curriculum 5 have deleterious effects on residents' professional development and investigated whether witnessing unprofessional behavior during residency was associated with burnout and cynicism.
  
  
  METHODS
  We surveyed internal medicine residents at 2 academic centers for 3 years (2008-2010). Hidden curriculum items assessed exposure to unprofessional conduct. We used regression analyses to examine if hidden curriculum scores were associated with cynicism and the Maslach Burnout Inventory depersonalization and emotional exhaustion domain scores.
  
  
  RESULTS
  The response rate was 48% (337 of 708). In the 284 surveys analyzed, 45% of respondents met burnout criteria and had significantly higher hidden curriculum scores (26 versus 19, P < .001) than those not meeting criteria. In cross-sectional analyses, the hidden curriculum score was significantly associated with residents' depersonalization, emotional exhaustion, and cynicism scores. Cynicism scores were also associated with burnout.
  
  
  CONCLUSIONS
  Exposure to unprofessional conduct was associated with higher burnout and cynicism scores among internal medicine residents. We also found that cynicism and burnout were significantly associated and 5 be measures of similar but not necessarily identical responses to the challenges posed by residency. Measuring the hidden curriculum and cynicism 5 provide direction for educators attempting to reform hospital culture and improve resident well-being.
authors.forename: Martha E
authors.initials: ME
authors.lastname: Billings
authors.forename: Michael E
authors.initials: ME
authors.lastname: Lazarus
authors.forename: Marjorie
authors.initials: M
authors.lastname: Wenrich
authors.forename: J Randall
authors.initials: JR
authors.lastname: Curtis
authors.forename: Ruth A
authors.initials: RA
authors.lastname: Engelberg