Building Your Own Boxes: Training and the Hidden Curriculum of Academic Success

A new viewpoint published in Academic Psychiatry is drawing attention across the medical education community for its candid examination of a problem few institutions name openly: the disorientation that many newly minted attending physicians experience when the structured checklist culture of training suddenly evaporates. Written by Dr. Elizabeth R. Steuber, a child and adolescent psychiatrist at Boston Children’s Hospital, the essay argues that medical training produces what she calls “excellent box checkers” — physicians superbly equipped to meet externally defined benchmarks but often poorly prepared to author their own professional goals once those benchmarks disappear. Drawing on her own transition from fellowship to her first attending position as an inpatient psychiatrist, Steuber weaves personal narrative with established theory in professional identity formation to make the case that the trainee-to-faculty transition deserves recognition as a formal developmental stage in its own right.

The central concept anchoring the piece is the “hidden curriculum,” a term with deep roots in the medical education literature. First articulated in a landmark 1998 paper by Frederic Hafferty, the hidden curriculum refers to the unwritten, informal, and often unintended lessons that medical trainees absorb alongside the official syllabus — the norms, values, and behaviors that are modeled rather than taught. Steuber’s contribution is to extend this framework into a specific and underexamined domain: achievement itself. During medical school, residency, and fellowship, she writes, achievement was synonymous with moving efficiently from one benchmark to the next. Clinical competencies, supervision hours, presentations, evaluations, leadership roles, and scholarly productivity all arrived as clearly defined boxes. The structure provided accountability, direction, and what she describes as a reassuring sense of forward momentum. But the very system that reliably produced a competent clinician, she argues, carried a hidden lesson — that progress means completing tasks someone else has defined — and that lesson becomes a liability the moment training ends.

The mechanics of this transition are more disorienting than many outside medicine appreciate. When a physician moves from trainee to attending, the external scaffolding does not merely loosen; for many purposes it vanishes. During training, academic development unfolds within a stable, predictable architecture: firm deadlines, scheduled mentorship meetings, conference submission cycles, and articulated milestones that allow supervisors to assess professional growth against defined parameters. As an attending, those parameters dissolve. Steuber describes confronting questions that were simultaneously more abstract and more personal than anything training had asked of her: What kind of academic psychiatrist did she want to become? Which projects felt genuinely meaningful rather than merely strategically advantageous? How should finite hours be divided among patient care, teaching, scholarship, mentorship, and institutional service? And, perhaps most piercingly, which opportunities actually aligned with her values, and which were driven by anxiety about falling behind? These are not questions that competency frameworks answer, because competency frameworks were never designed to ask them.

What makes the essay particularly resonant is Steuber’s insistence that her discomfort was not a sign of incompetence. This distinction matters technically as well as emotionally. Research on the transition from resident to attending physician — including a widely cited transdisciplinary qualitative study by Westerman and colleagues — has documented that new attendings routinely experience this period as a profound identity shift, not simply an escalation of workload. Steuber’s account aligns with that literature while adding a sharper analytical edge: she argues that much of the unease stems from unfamiliarity with unmeasurable growth. Having internalized productivity, efficiency, and advancement as proxies for professional worth across years of reinforcement, the new faculty member instinctively searches for reassurance that she is progressing “appropriately” — even though no universally accepted timeline or checklist exists for the stage she has entered. The drive to move forward remains unchanged from training, she observes, but the roadmap has largely disappeared.

The theoretical foundation for this argument comes from a body of work asserting that competency alone is insufficient preparation for physicianhood. In a 2012 paper in Academic Medicine, Jarvis-Selinger, Pratt, and Regehr argued that identity formation must occur alongside, not after, skills acquisition. Steuber takes this claim and applies it to the faculty transition with a pointed observation: training environments understandably emphasize measurable progression, and over time achievement itself can become internalized as identity. The reflective, deliberative process of constructing a sustainable professional identity — deciding what one’s work should mean, not just what it should produce — receives comparatively little explicit attention. The result is a structural asymmetry: physicians are extensively prepared to obtain attending positions but may receive far less preparation for the emotional and professional realities of becoming attendings. The uncertainty of early faculty life, she notes, is typically normalized only informally, through near-peer conversations and hallway mentorship, rather than being openly incorporated into the curriculum.

One of the most counterintuitive findings in the essay concerns the value of time that appears, by conventional metrics, least productive. Steuber reports that the experiences that proved most valuable during her transition were those that initially felt least “productive” during fellowship — elective periods that offered rare opportunities to explore interests without immediate pressure for measurable output. During those windows she observed different leadership styles, encountered different patient populations and care settings, tried new projects, and considered which aspects of psychiatry felt sustaining beyond achievement alone. In retrospect, she writes, elective experiences were among the few parts of training that encouraged identity exploration rather than performance optimization. This finding has practical implications for program design. Electives that look inefficient on paper — opaque in their outcomes, resistant to milestone mapping — may in fact be cultivating precisely the capacities that predict long-term academic sustainability: curiosity, self-direction, and reflective career development.

The essay situates these observations within a broader movement in academic medicine. The field has invested heavily in physician wellness, mentorship, and professional development, with influential frameworks from scholars such as Cruess, Cruess, and Steinert on supporting identity development, and Wald on professional identity transformation through reflection, relationship, and resilience. Steuber’s argument is that the transition from trainee to faculty deserves comparable attention and comparable resources. She calls on training programs to explicitly teach career self-direction alongside clinical competency — a proposal that, if implemented, would represent a meaningful curricular shift. Concretely, she advocates structured conversations about professional identity formation, ambiguity tolerance, academic values, and the nonlinear nature of career development. Ambiguity tolerance, in particular, is a skill with psychological literature behind it: the capacity to remain effective and motivated under conditions of unclear feedback is trainable, and its absence is a recognized contributor to burnout and attrition in early-career clinicians.

The stakes of getting this wrong are not trivial. Early faculty attrition, imposter phenomena, and the mismatch between trainee expectations and faculty realities are persistent concerns in academic medicine. When new attendings interpret the absence of external structure as personal failure, the consequences can include overwork, unstrategic project-taking driven by anxiety, and erosion of the very curiosity that brought them into academic careers in the first place. Steuber’s reframing — that untethered feelings may signal a developmental transition that medical education has not fully taught physicians to expect, rather than individual inadequacy — offers a corrective that is both psychologically protective and institutionally actionable. It shifts responsibility from the individual clinician’s resilience to the educational system’s completeness, asking programs to close the gap between the competencies they certify and the capacities their graduates will actually need.

For physicians approaching graduation, the essay closes with a message that is already circulating widely on academic social media: if attending life occasionally feels untethered, it does not mean you are failing. The absence of clearly defined boxes can feel genuinely uncomfortable after years spent mastering how to complete them efficiently — but there is opportunity embedded in that discomfort. Steuber’s final formulation is likely to become quotable: at some point, professional growth becomes less about checking the next box and more about deciding which boxes are worth creating at all. It is a deceptively simple sentence that condenses a substantial theoretical claim — that self-authorship is a learnable skill, that it requires protected space to develop, and that educational systems which reward only performance optimization will systematically underproduce it.

As a piece of scholarship, the essay is modest in form — a viewpoint, a single author’s reflection, no datasets or statistical analyses — but its timing and framing give it outsized relevance. Medical education is in the midst of a prolonged reconsideration of competency-based frameworks, time-variable progression, and the well-documented costs of achievement culture on trainee mental health. Steuber’s argument extends that reconsideration past the finishing line of graduation, into the early faculty years where the hidden curriculum of achievement finally presents its bill. Whether programs respond by building structured identity-formation curricula, protecting exploratory elective time, or simply naming the transition openly, the essay makes a clear contribution: it gives a common and painful experience a vocabulary, a theoretical lineage, and a set of institutional remedies. For a profession built on checklists, learning to make your own boxes may be the next competency that matters most.