Fairy Tales We Teach Without Telling: Transformative Learning and the Hidden Curriculum in Medical Education

Introduction

Medical education extends beyond the pure transmission of biomedical knowledge and clinical skills. It also shapes how learners understand patients, their own professional identities, and the norms prevalent in healthcare practices. While formal curricula transmit explicit competencies such as knowledge and practical skills, learners are simultaneously exposed to a so called hidden curriculum: the implicit values, assumptions, hierarchies and biases conveyed through teaching practices, everyday interactions with teachers and learners, and institutional cultures.^1,2 The hidden curriculum influences how future health professionals understand whose bodies, experiences, and perspectives are considered standard, visible, or legitimate within the medical system.^3–6

Transformative learning theory offers a useful framework for examining these processes, as it emphasizes critical reflection on previously unquestioned assumptions and the development of new perspectives through dialogue, experience and reflection.⁷ Within medical education, transformative learning has increasingly been recognized as essential for preparing practitioners capable of navigating complexity, uncertainty, and inequity.^8–10 Such learning requires not only engagement with formal knowledge, but also attention to the hidden structures that shape how knowledge is produced, reproduced, taught, and enacted.

To explore the role of the hidden curriculum and its addressing by transformative learning theory in medical education, this manuscript adopts a narrative approach in the form of a fairy tale. Narrative methodologies have been employed in health professions education to illuminate aspects of learning that often remain inaccessible to conventional academic discourse alone.^11–14 Fairy tales provide a space for allegory, ambiguity, and interpretation, enabling readers to engage with complex educational phenomena from a critical distance. The Academy, the Hall of Reference, the whispering walls, and the mythical figures encountered throughout this narrative act as literary devices through which hidden assumptions, educational structures, and transformative possibilities may be brought into view. Readers are therefore invited to engage with the story as a reflective text.

The Academy

Once upon a time, there was an Academy. The Academy stands at the center of the city, built of stone and elite tradition. Its doors are open to all who seek to learn how bodies are understood, measured, and treated. Old stone on stone, heavy doors to keep out the chaos, let the clearness in. The walls speak a language of certainty. The Academy stands for its precision and years of knowledge production. Those who pass through its gates are told that what is taught here applies universally, across places, lives, and forms of embodiment. Inside, long corridors lead to lecture halls where diagrams line the walls.

The Academy has the best teachers this side of the dark forest. Years of apprenticeship, they must know and teach the standards by heart. With every word they teach, they emphasize accuracy, efficiency, and objectivity. They remind students that medicine must rely on evidence, that personal impressions are unreliable, and that good practice depends on distance as much as on care.

Knowledge in the Academy is organized into systems. The Academy is known for its universal standards. Bodies are rendered in clean outlines, carefully labeled, stripped of excess and variation. These bodies are presented as reference points: stable, comparable, reliable. In the center of the Academy is the famous library – the Hall of Reference. Inside are a trillion of heavy, authoritative, and widely shared books. Their pages describe the patient, the disease, the body. The language is precise and restrained. The knowledge inside the books is free from context, history, or perspective. Differences appear only as variations from a presumed norm, addressed in separate chapters or footnotes. Students are taught to recognize them quickly and to trust what can be seen, named, and standardized. Symptoms follow standard pathways. Interventions follow protocols. Uncertainty is framed as something to be resolved, ideally before it reaches the bedside. What cannot be clearly classified is deferred, referred, or noted in the margins.

Those who learn within its walls are thankful and proud to be a part of the Academy. The learners quickly understand what is expected. To succeed, one must master the material, reproduce it accurately, and apply it without hesitation. The curriculum is clear. And yet, beneath this clarity, something else quietly circulates. Not written, not examined, but steadily absorbed.

The Learner

Each year, new learners arrive at the Academy. They come from different places, yet all want to become the best physicians. Excited, with trembling hands and broad smiles above their academy uniforms, they receive their study schedules, assigned seats, and directed toward the same halls. From the beginning, they are told that what they will learn here applies equally to all who enter and to all outside the Academy.

Among the new arrivals, the Learner sits quietly in the first row. But this Learner comes from the other side of the dark forest, where no two bodies are alike, where fur and claws can coincide with scaly, glittering skin. As excited as the others, the Learner sets off. The Learner opens the books assigned to them, tracing the diagrams with careful fingers. The Learner memorizes the sequences, repeats the terminology, follows the protocols. The Learner answers all questions correctly. The Learner does not draw attention. In the Academy, this is considered success.

The Hall of Reference is all the Learner ever dreamt of: tall shelves, orderly volumes, a quiet that feels both solemn and demanding. Every page promises clarity, every chapter a formula for understanding the world of bodies.

Yet, after the first year of lectures, a subtle dissonance stirs. Instructors speak of certain patients with ease, while others are described with caution. Some bodies are marked as “complex”, some as “challenging”, some are almost whispered about in the hallways, never appearing in the official diagrams. The walls themselves seem to join in the murmurs. In quiet moments, when the Learner lingers over a diagram or closes a book, faint voices drift from the stone and shelves. They are not words exactly, but suggestions, judgments, echoes of past lessons. “Atypical,” they say. “Unusual”. “Take care with this one”. The flutters of speech slip through cracks in the mortar, brushing past the learner’s ears.

“Something does not quite fit between what is taught in the books and what is spoken in passing”, the Learner thinks. “The standards are supposed to apply to all bodies, yet some seem to slip through the logic of the Academy, treated differently, measured by unspoken rules”.

At night, in the Hall of Reference, the Learner pores over the texts. The Learner sees the same diagrams, the same definitions, the same universality. Yet the Learner cannot reconcile the written knowledge with the whispered lessons. It is as if the margins of the books were alive with what cannot be named.

Teaching and the Hidden Curriculum

During teaching rounds, the Learner observes carefully. Cases are presented with authority and precision. Certain bodies are described with confidence, others with caution. Some patients are “typical,” others “challenging” or “atypical”, their bodies rarely appearing on slides, yet always present in whispers between instructors. Difficulty is rarely about the body alone; it is about who is speaking, what is assumed, what is left unsaid. The rules are the same for everyone, yet some bodies are measured differently, judged subtly, treated as exceptions.

Later, in the Hall of Reference, the Learner returns alone. The walls seem to murmur. Soft echoes of past lessons drift from the stone and shelves. The Learner leans close, asking silently: “How am I meant to reconcile this? How do I measure bodies that do not fit?” The walls reply, almost uniformly, almost mechanically: “The standard is standard, for it applies to all”. “Deviation must be corrected”. “What is written is universal”. The Learner listens. The books are open, diagrams traced, definitions memorized. Still, the whispers persist, repeating rules without explanation, highlighting the tension between instruction and reality. No answers are given. Only the repetition of what already is. And so, the seed of questioning takes root.

When the clock strikes midnight, the Learner leaves the Hall with a sense of critical consciousness: Knowledge is not only what is taught. It is enforced, echoed, shaped by its own authority, and that understanding requires listening not just to words, but to the silences between them.

The Elf and the Giant

One morning, during a teaching round, the Learner encounters two cases that linger in memory like shadows. The first is an elf with a long beard. Small, delicate, quick to recover from interventions, their symptoms subtle but persistent. The Learner follows the prescribed assessments, applies the standard protocols. Everything fits… almost. Yet every measure seems to understate the elf’s experience. The second is a giant with scaly-like skin. Resistant to the same treatments, slow to respond. Instructors speak of these cases with visible strain: “Atypical”, they whisper. “Not as usual. Never seen”. “They take too much time. You must manage expectations”. The protocols, identical on paper, feel insufficient in practice. The Learner wonders: “How can the same knowledge claim to apply equally to both? Why is one treated as standard, the other as atypical exception?”

In the Hall of Reference that evening, the Learner returns, seeking guidance. The Learner whispers to the walls: “How should I measure them? How can one standard fit all?” The walls answer as always, without variation: “The standard is standard. It applies to all”. “Deviation must be corrected”. No other guidance comes. The books are open, diagrams traced, margins empty of insight. Yet the Learner cannot unhear the dissonance: the elf fits the standard too easily, the giant too poorly. Something in the system, its assumptions, its language, its rule, has made one case appear normal and the other difficult.

For the first time, the Learner feels a weight beyond memorization. The Learner realizes that knowing the rules is not enough; learners must understand how the rules shape perception, how authority shapes attention, and how silence can make some bodies invisible. The Learner remembers the various bodies that live on the other side of the dark forest, where they come from. How to care best for all?

Transformation

Years pass, where the Learner tries to follow the formal requirements of the Academy at day, and asks the walls in the Hall of Reference at night. The Learner reflects quietly on the rounds, on the whispers of the walls, on the elf and the giant. The Learner fell torn between the standard and their critical reflections. The Learner recites the protocols flawlessly, answer questions with precision, and pass every examination. In the eyes of the instructors, the Learner is competent, reliable, exemplary. The books are correct, the diagrams memorized, the procedures performed without error.

But the Learner has recognized that knowledge is not neutral. Those standards, though applied to all, are shaped by assumptions, by the expectations of teachers, by the habits of the Academy, by what the system has historically decided to value or ignore. The Learner understands that mastery of the curriculum does not guarantee mastery of the world beyond the lecture halls of the famous Academy. To care and to heal, the Learner will need more than procedures; the Learner will need attentiveness, curiosity, and the courage to question.

And yet, the Learner also recognizes the logic of the Academy. The examinations do not measure curiosity, they do not measure reflection. They measure the ability to apply the knowledge that the Academy has deemed important. Success within this system does not require disruption; it requires comprehension. So, the Learner succeeds, and in succeeding, learns something unexpected:

To change the Academy, one must first understand its rules. To understand the world, one must first navigate its structures. Knowledge as it is taught is not always knowledge as it could be.

This realization is uncomfortable, quiet, and persistent. It does not produce immediate change. But it plants a seed of the awareness that the Learner can exist inside the system transforming it.

In the quiet that follows the final grand examinations, the Learner wanders once more through the Hall of Reference. The shelves stand unchanged, the diagrams remain, the standards still declared universal. Yet now, the Learner sees the gaps, the margins, the whispers of what has been left unspoken. The Learner now knows that the Academy is not a neutral space. It preserves knowledge, organizes it, repeats it; but it does not question itself. The Learner understands that mastery alone does not alter these structures.

And for the first time, the Learner imagines something different. Not a rejection of what has been learned, but a way to inhabit it differently. To teach differently. To speak with the walls, with the books, with the instructors, not to defy, but to transform from within.

The work of transformation is not sudden. It is not complete. But its first steps are taken. The Learner has passed the examinations, yet their reflection continues. And in that reflection lies the possibility: the Academy might one day learn to speak a new language. The new language is not just of bodies and protocols, but of attention, questioning, and care.

From Learner to Teacher

The final year passes. The Learner completes the curriculum, passes the exams, and is now permitted to heal. Because the Learner had mastered every test, recited every protocol with care and precision, the Learner was invited to take up a new role: to teach. The Academy, in its quiet wisdom, recognized ability, and so the Learner became a teacher.

The halls remained the same: stone corridors, towering shelves, diagrams that promised certainty. Yet now, the Learner’s voice carried weight. The once Learner, now Teacher spoke in lecture halls where echoes of past lessons lingered and where students listened as they once had.

At first, the teaching followed the old pattern. The books were opened, the standards recited, the routines observed. But quietly, almost imperceptibly, the Teacher began to pause in the midst of instruction. The Teacher lingered over the diagrams. Even as a Teacher, they noticed it: the soft undercurrent that ran beneath every lesson, beneath every protocol, beneath every diagram. The whispers of the walls, the sidelong remarks in lecture halls, the invisible marks that determined which bodies were “typical” and which were “difficult”, which diagrams were displayed in the corridors and which were only found in the special chapters: all of it shaped understanding as much as the books themselves. Now, with a measure of authority, the Teacher began to illuminate these quiet rules by drawing attention to the silences, pointing toward the margins, and inviting students to listen to what had always been there, just out of sight. The Teacher asks questions that had no single answer. The Teacher invites the students to notice the margins, to consider the whispers of the walls, to hear the silences between what was said and what was assumed.

In the Hall of Reference, late at night, the Teacher returned as they once had as a learner. The Teacher leans close to the stone walls and murmured softly: “How might this standard serve all? What is assumed here? What is left unspoken?” The walls replied as they always had: “The standard is standard. It applies to all”.

But now, the Teacher does not merely listen. The Teacher traces their own notes and echoes in the margins, sketches connections between lessons, writes in the spaces between, and lingers over exceptions that had never been addressed. The books, once silent and unyielding, seemed to hum in response. The Teacher shows them that the hidden could be seen, named, and reflected upon. They were no longer only authorities to be memorized. They became spaces for reflection, dialogue, and subtle challenge.

Though the Academy itself did not change overnight, and the protocols remained as they were, a new current flowed through the halls. Students began to see, if only faintly, that knowledge was not a fixed treasure, but a living river, to be navigated with care, curiosity, and courage.

Students Becoming Change-Makers

One day, the Teacher invited the elf and the giant that the Teacher met during their round as Learner years ago. The Teacher asked the students how to apply the standard to both. The students whispered: “But how can we apply the standard to both of them, as their bodies, their embodiments, their needs are so variable?” The Teacher smiled: “Excellent question!” “What a disorienting dilemma!” said one student.

Over time, the students noticed what their Teacher had quietly shown them: that the Academy was not only a place to memorize, but a place to question. They lingered over the margins of the Hall of Reference, tracing the diagrams and reading between the lines. They whispered to the walls as their Teacher once had, asking not only how the standards applied, but why they applied at all.

Over the summer, the Teacher invited the students to change the standards. Some took the books into their own hands. They added notes, drew new connections, and sketched alternative diagrams for elves and giants alike. They invited giants and elves to co-design giant- and elves-protocols for elves with beards, without hair, for tall and small elves, for giants with scaly skin, with long hair on their feet, and giants with soft voices and soft hearts. They experimented with guidelines that had once seemed fixed, considering what might be fair, what might be possible, what might be overlooked. In the lecture halls, students began to speak up. They suggested adjustments, questioned assumptions, and shared observations from practice. Protocols that once felt rigid began to shift, ever so slightly, in response to lived experience. The whispers of the walls were no longer the sole voice of authority; they became part of dialogues and discussions, a chorus that included both the books and the students themselves.

And through this subtle activity, the Academy began to transform. The invisible became a presence in the Academy, not as a threat, but as a companion to learning: a quiet reminder that knowledge carries both what is said and what is left unsaid, and that wisdom may lie in attending to both. The knowledge that had once been universal and unquestioned now bore the marks of experience, reflection, and imagination. Students learned that to care for bodies, whether elf, giant, or otherwise, required more than memorization: it required attention, curiosity, and practice. It required reflection, structural knowledge, and the courage to act on insight.

The seed that had been planted in one attentive learner had grown into many: a quiet forest of curiosity, shaping the Academy from within. Transformation was now alive in the students themselves.

The Fairy Tale Ends (For Now)

And so, the story pauses here. Not because the work is done, but because fairy tales end where responsibility begins.

The Academy still stands, its halls filled with books, diagrams, and protocols. Students still come and go, learning, memorizing, reciting. But something has shifted in the quiet spaces between lessons. The standards remain, yet they are now seen differently. The knowledge they contain is no longer absolute; it can change, grow, and be shaped by those who attend to it. Those who teach, once silent keepers of authority, are now reminded of the worlds their words sustain. Every lesson carries weight. Every whisper matters. Every margin may hold a question that shapes the way students see and care for others. Within its walls, the seed of transformation lives: a forest of curiosity, reflection, and attentiveness, patiently unfolding. The story ends here, but the work, the learning, and the reflection continue, insistently, in the hearts and hands of those who listen and act. Those who transform.

Discussion

Meta-Reflection: Why a Fairy Tale?

This story employs the form of a fairy tale to deconstruct traditional modes of knowledge production in medical education. Fairy tales operate in a realm of ambiguity, imagination, and symbolism. They allow readers to encounter familiar situations – here medical training, academic institutions, hierarchies, and clinical protocols – through metaphor, allegory, and exaggeration rather than literal representations, case reports, or empirical accounts. In this narrative, mythical patients such as elves and giants, whispering walls, and the Hall of Reference function as literary devices that make visible the hidden curriculum: the unspoken rules that learning means memorizing rather than critically engaging with teaching content, implicit biases, and normative expectations regarding who is considered a successful medical student or teacher, whose bodies, diseases and symptoms are considered relevant and integrated in clinical guidelines, and whose bodies are othered aside the formal curriculum of biomedical knowledge and clinical skills that shape learners’ understanding of bodies, illness, and professional conduct.

The broader narrative structure offers an additional analytical perspective on transformative learning. The Academy can be conceptualized as academic medical education and its orientation toward standardized knowledge, while the Hall of Reference can be understood as the institutionalization of particular forms of evidence and expertise. The whispering walls refer to the hidden curriculum, which transmits implicit assumptions, values, and judgments that exert considerable influence on learners’ attitudes, professional identity formation and clinical reasoning. Similarly, the figures of elves and giants function as representations of bodies and experiences that are inadequately recognized within prevailing medical paradigms. Their inclusion underscores the ongoing tension between universalized standards and the diversity of embodied experiences encountered in clinical practice. In the context of diversity- and sex- and gender-sensitive medical education, these figures further elucidate the ways in which purportedly universal standards may systematically advantage certain bodies and experiences, simultaneously marginalizing others.

The narrative aligns with transformative learning theory by Mezirow,⁷ further applied in health professions education.^8–10 The Learner’s journey reflects a classic pattern of transformative learning: a (or multiple) disorienting dilemma(s) (the living beings from the other side of the dark forest, the elf and giant cases), critical reflection on assumptions and attitudes,^15,16 and gradual development of critical consciousness,^17,18 structural competency¹⁹ and cultivation of agency to question and act within the system to transform the system.^8,20 Since the learner comes from the other side of the dark forest, where bodies do not conform to the Academy’s textbooks and guidelines, their perspective can be understood as one from the margins confronted with epistemic injustices themselves.^21,22 By tracing the Learner’s progression to become a teacher who models and guides reflection, self-growth and critical consciousness, the story illustrates how transformative learning can be both personal and collective, fostering learners who not only to absorb knowledge but also interrogate and reshape it. Notably, transformation within the narrative is depicted not as an isolated achievement, but as a collaborative and ongoing endeavor, manifest in the shared efforts of learners and teachers to revise curricular content, interrogate normative standards, and generate novel forms of knowledge. In this sense, the narrative demonstrates how transformative learning may extend beyond individual perspective shifts to encompass the transformation of educational cultures, practices, and systems. The Learner/Teacher is explicitly kept anonymous and impersonal: We are all learners; we are all teachers.

Taken together, this narrative contributes to scholarship on transformative learning by illustrating how hidden curricula, language, and epistemic norms shape what is considered legitimate knowledge, and who is a legitimate learner or teacher in medical education.²¹ The fairy tale framework not only describes transformative learning but also enacts it by externalizing the dynamics in imaginative form, inviting readers to engage in interpretation, question assumptions, and imagine alternative educational possibilities. It emphasizes that learning is about cultivating curiosity and creativity, critical consciousness, and ethical responsibility. It is embedded in (academic) culture, language, and power. The fairy tale may itself serve as a pedagogical, transformative learning resource: For educators, this highlights the importance of creating learning environments that encourage reflection, dialogue, and epistemic humility. Educators could use it to initiate dialogue about hidden curricula, epistemic assumptions, and the social construction of medical knowledge. For learners, it underscores the possibility of becoming not only consumers of knowledge but active participants in its ongoing transformation. Learners may engage with the narrative as a reflective exercise, identifying moments of dissonance, reflect on norms and assumptions, and considering how they themselves participate in reproducing or challenging existing norms, dominant knowledge structures, and encourage learners to imagine and practice alternative possibilities for medical education and practice. For researchers, the narrative demonstrates how narrative and allegorical approaches can complement traditional, mostly quantitively based scholarly discourse by making visible the relational, cultural, and often implicit dimensions of teaching, learning, and research within medical education.²³ In this sense, the fairy tale does not merely describe transformative learning; it may also create conditions for it. Storytelling, especially in allegorical, narrative and imaginative forms, provides a vehicle for educators, learners and researchers alike to confront assumptions, explore ambiguity, and participate in the ongoing co-creation of more equitable, reflective, and responsive medical practice.¹¹ The story’s ending “The Fairy Tale Ends (For Now)” signals that learning and transformation are continuous processes, inviting readers to think about their own fairytales of teaching and take up the responsibility of critical reflection and action in their own educational practice.

Conclusion

This manuscript employs an allegorical fairy tale to examine transformative learning in medical education, with a particular focus on the hidden curriculum, epistemic authority, and the construction of standardized medical knowledge. The narrative illustrates that transformation in medical education is not solely an individual cognitive process, but a relational and cultural process embedded within institutional language, practices, and hierarchies. It contributes to medical education scholarship by demonstrating the potential of narrative and arts-based approaches to complement transformative learning theory and hidden curriculum research. This approach broadens methodological perspectives for understanding the processes through which knowledge is legitimized, how professional identities are formed, and how implicit norms shape medical reasoning and education.

In practice, the narrative underscores the importance of making implicit curricular messages visible and cultivating learning environments that facilitate reflection, dialogue, and epistemic humility. For educators, the narrative can serve as a tool to facilitate discussion of hidden curricula and teaching practices. For learners, if offers an entry point for critical reflection on how standards and assumptions shape clinical understanding and professional identity. For researchers, it illustrates how narrative methods can be used to access the relational dimensions of medical education that are often difficult to capture through conventional approaches.

In conclusion, the manuscript invites further exploration of narrative approaches in health professions education, transformative learning in clinical contexts, and hidden curriculum research as a dynamic field concerned with how knowledge is produced, shared, and transformed in practice.