Hidden Curriculum Blocks Doctors From Learning to Fight for Their Patients

Medical schools around the world have long promised to produce not just competent clinicians but socially engaged physicians who understand that health is shaped by far more than biology. Yet a new study from Brazil suggests that one of the most important competencies in that promise — health advocacy — is being quietly squeezed out of the curriculum, not by deliberate design but by institutional inertia. The research, published in BMC Medical Education, examined how professors responsible for teaching primary health care at the Faculty of Medicine of the University of São Paulo (FMUSP), one of Latin America’s most prestigious medical schools, perceive and teach the ability to advocate for patients and communities. Their answers reveal a striking paradox: the richest opportunities for teaching advocacy already exist inside everyday primary care teaching, but they remain largely invisible to the institution that houses them.

Health advocacy, as defined by the widely used CanMEDS framework of medical competencies, involves far more than treating the patient in front of you. It requires physicians to recognize health needs that patients themselves may never voice, to mobilize resources on their behalf, and to promote changes that advance health equity in collaboration with individuals and communities. In a country like Brazil, where the constitutionally guaranteed Unified Health System (SUS) was built on the principle of universal, comprehensive care, this competency carries particular weight. The country’s National Curriculum Guidelines for medical education explicitly emphasize comprehensive care across all levels of the health system, and they call for the development of ethical, critical, and socially engaged professionals. Still, the study’s authors note that translating these aspirations into actual teaching practice remains a persistent challenge for medical educators everywhere.

To understand how advocacy is actually taught — or not taught — the research team, led by Mariana Eri Sato of FMUSP’s Primary Health Care Supervision unit together with Márcia Oliveira Mayo Soares and Milton Arruda Martins, turned to a qualitative, hermeneutic approach. Rather than surveying a large sample with fixed questions, the researchers convened a focus group with eleven professors drawn from six different specialties: Gynecology and Obstetrics, Pediatrics, Psychiatry, Preventive Medicine, Internal Medicine, and Family and Community Medicine. Crucially, every participant was actively engaged in teaching primary health care to undergraduates, meaning the discussion captured the perspectives of the very faculty members tasked with delivering this content. The session was audio-recorded, fully transcribed, and then analyzed through comprehensive interpretive reading, a technique in which researchers immerse themselves in the material to identify recurring analytical categories. Those categories were subsequently interpreted in light of established theoretical frameworks in medical education, and the study received ethics approval from the Research Ethics Committee of FMUSP’s Hospital das Clínicas, with informed consent obtained from all participants.

The single most consistent theme to emerge from the discussion was the difficulty of teaching students to identify health needs that go beyond the explicit demands patients bring into the consultation room. A patient may present with back pain, for example, while the underlying issue is unsafe housing, unemployment, food insecurity, or untreated depression that the patient never mentions. Learning to see these hidden dimensions — and to connect the care of one individual patient to the collective health of the community they belong to — is, in the professors’ view, the central educational challenge of advocacy. It demands a fundamental shift in clinical reasoning, from the classic biomedical model that asks ‘what disease explains this symptom?’ to a broader question: ‘what social and structural forces are shaping this person’s health, and what can I do about them?’

For all these difficulties, the participants were remarkably unified on one point: primary health care is a privileged setting for learning advocacy. Unlike a hospital ward, where patients appear as isolated cases stripped of context, primary care embeds future doctors in communities over time. Students working in primary care settings witness firsthand how social determinants of health — income, education, sanitation, access to transport — translate into disease and suffering. They see families across generations, follow patients through the consequences of policy decisions, and encounter the gap between what the health system promises and what it delivers. In the Brazilian context, where SUS organizes care around territorial responsibility and community engagement, primary care offers an almost laboratory-like environment for observing the interplay between medicine and society.

Yet the professors also identified a sobering institutional reality: the contribution of primary health care to the curriculum is often undervalued. Within the culture of academic medicine, where high-technology hospital specialties traditionally command prestige, the intellectual and social richness of community-based teaching can be dismissed as secondary. This devaluation is not merely symbolic. It shapes how resources are allocated, how teaching time is protected, and how seriously students take their primary care rotations. When the institutional signal suggests that advocacy and community health are peripheral concerns, students absorb that message regardless of what the official curriculum says.

Indeed, the study’s most consequential finding concerns the nature of the obstacles themselves. The professors did not point primarily to pedagogical problems — a lack of teaching techniques, materials, or know-how. Instead, the barriers they identified were institutional: curricular fragmentation that slices learning into disconnected blocks, assessment systems that fail to measure advocacy competencies at all, and the hidden curriculum, the unwritten norms and values that students absorb by watching what is rewarded and what is ignored. Curricular fragmentation is particularly corrosive for advocacy, because advocacy is inherently integrative; it requires students to bridge clinical care, public health, ethics, and social analysis, precisely the connections that fragmented curricula tend to sever. And assessment gaps matter enormously in competency-based education, because what is not tested is, in practice, not taught. If students are never evaluated on their ability to recognize unvoiced health needs or mobilize community resources, they quickly learn that these skills are optional.

The hidden curriculum deserves particular attention because it operates beneath the level of formal instruction. Students learn from what their teachers model, from the jokes told in the corridor, from which rotations are described as ‘real medicine’ and which are treated as boxes to tick. If hospital-based, procedure-oriented faculty implicitly convey that advocacy is soft or political work unworthy of a serious physician, no amount of lecture content on social determinants will counteract that message. Conversely, the study suggests, the same mechanism can work in favor of advocacy when it is made deliberate: faculty who visibly advocate for their patients, who name the social forces behind a clinical problem, and who treat community engagement as core medical work transmit a powerful counter-message.

That is precisely where the study’s conclusions offer grounds for optimism. The participants identified a set of strategies already embedded in primary health care teaching at FMUSP that could serve as underrecognized vehicles for developing advocacy: role modeling by engaged faculty, the Person Centered Clinical Method (PCCM), small-group learning, and reflective portfolios. Each of these tools, the researchers argue, already pushes students beyond the biomedical gaze. The Person Centered Clinical Method explicitly trains students to explore the patient’s illness experience, context, and goals, creating natural openings for identifying unvoiced needs. Small-group learning allows students to discuss difficult cases collectively and to practice articulating the collective dimensions of health. Reflective portfolios ask students to make their values and observations explicit, turning tacit experience into conscious learning. The problem is not that these methods fail to teach advocacy; it is that nobody has named them as advocacy teaching, and so their contribution goes unrecognized, unsupported, and unassessed.

The study’s practical implication is therefore deceptively simple: make the invisible visible. By explicitly framing existing primary care teaching practices as health advocacy education, aligning assessment systems with that framing, and securing institutional support for community-based teaching, medical schools could embed advocacy across the curriculum without inventing new courses from scratch. For a world grappling with widening health inequities, aging populations, and the mounting burden of diseases rooted in social conditions, the stakes extend well beyond one Brazilian institution. The FMUSP professors’ experience suggests that the future of advocacy in medicine may depend less on adding content than on recognizing, rewarding, and protecting the teaching that is already happening — often in the least glamorous corners of the medical school, where students first learn what it truly means to stand up for a patient.

Subject of Research: Teaching health advocacy competency in primary health care medical education

Article Title: Teaching health advocacy in primary health care: a qualitative study with professors from the University of São Paulo medical school

Article References: Sato, M. E., Soares, M. O. M., & Martins, M. A. (2026). Teaching health advocacy in primary health care: a qualitative study with professors from the University of São Paulo medical school. BMC Medical Education. https://doi.org/10.1186/s12909-026-10587-y

Image Credits: AI Generated

DOI: 10.1186/s12909-026-10587-y

Keywords: medical education, health advocacy, primary health care, qualitative research, social determinants of health, competency-based education, CanMEDS framework, hidden curriculum, Brazilian Unified Health System, University of São Paulo, curriculum reform, faculty perspectives