Deepening Trauma-Informed Medical Education

Trauma and chronic stress result in real and measurable biological dysfunction.^1-6 The effects of trauma can be mitigated via intentional and sustained increases in real and perceived safety (physical, psychological, social, and moral) often accompanied by addressing past harms from a position of real and present security.^7-10 This is the basis of trauma-informed care (TIC).

While much of the initial focus of TIC was on interactions with patients, psychiatrists in the early 1980s began to apply the principles of TIC to themselves, creating organizational development models (staff practices and interpersonal tools) rooted in TIC.¹¹ Further developments in trauma-informed practices have resulted in applications of the work more broadly to education and medical education in particular. Scholar-practitioners such as Alex Shevrin Venet¹² and organizations including Edutopia¹³ and the National Education Association¹⁴ promote trauma-informed education (TIE), and some colleges and universities have developed TIE certifications.¹⁵ The value and exercise of trauma-informed medical education (TIME) was described by McClinton and Laurencin in 2020 and by Brown et al in 2021.^16,17 While both articles touch upon the application of TIME to medical education delivery for the benefit of students and faculty, other scholars including Gerber, Jelley, and Potter¹⁷ refocus TIME as the intentional curricular integration of TIC competencies for patient care rather than for medical education itself.¹⁸

TIME mirrors the application of TIC in patient care. Despite the mounting evidence valuing TIC in the exam room,^7,8 there remains skepticism about its value in medical education largely due to what appears to be a fundamental misunderstanding of its application.¹⁹ Just as a TIC approach supports all patients, an educational system built on trauma-informed principles helps everyone, irrespective of roles and individual trauma histories. TIME is not intended to diminish accountability; it is not “filling in missing elements,” nor is it “avoiding direct critique.”¹⁹ Reducing accountability for demonstrating competence is a form of cruelty that is antithetical to TIME. Reducing accountability in medical education sets people up to fail without the needed support.

TIME as a framework for the learning environment as well as for curriculum development and delivery is the consistent application of intentional attention to the varieties of human experience in order to address challenges toward actual and holistic resolutions. As demonstrated in Table 1, TIME intentionally weaves the work of education with a supportive purpose, providing dependable structures and boundaries that allow everyone involved—not just those with a known trauma history—to know that what could have been done to grow and develop learners was done at both the individual and system levels.

These shifts move us away from a deficit view of the learner, a view that assumes they are empty or broken vessels awaiting intervention, and toward the recognition that we all have histories as well as the assets necessary to teach, learn, and grow.^12,21

Changing entire curricula and the culture of medical education takes more time than any single educator has. One potential step medical educators can take to experiment with a robust application of TIME is the elimination of time-limited testing. Weiner, Park, Gernsbacher, and Petersen lay bare “myths” that have ensconced time-limited testing and provide evidence-based alternative approaches.²² A potential faculty development pilot in TIME would be to facilitate the trauma-informed precepting module created by Brown et al, and ask faculty to practice applying the learning to peer teaching.²³ A more targeted option is to use TIME for professionalism reviews by adopting the model of the restorative justice or practice circle through an intentionally facilitated process where all relevant stakeholders are involved in a boundaried conversation that explores the issue through the principles of TIME.^24,25

TIME applied to the systems and delivery of medical education regardless of content goes beyond the trauma histories of individual learners and educators to acknowledge that trauma and harm have been at the root of traditional medical education. If we want the health care system to be different, we must educate differently. TIME is not about being lenient; it is about authentic thoughtfulness applied systemically to ensure everyone is accountable without being unduly harmed. Medical students and residents must learn the content, processes, and procedures required to provide excellent medical care. They must be able to engage with people of all kinds as equitably as possible. They must learn how to manage their time and resources, find the internal grit needed to push through discomfort in order to grow into licensed physicians. TIME, in acknowledging that human beings are emotional creatures whose past experiences inform their present responses, supports the challenging work of medical education to develop wholly human physicians who better understand themselves and their patients.