Who Will Teach the Teachers Themselves?

After giving a virtual talk on trauma-informed care (TIC) at a women’s health care conference for primary care clinicians, I received some conflicting feedback:

Brushing aside the positive feedback, I focused on the negative and felt like a bit of a failure. Trauma-informed care was not covered and seldom practiced in my medical school and residency, and I’d projected my own experience onto my audience. Even as I was grateful for the apparent sea change that had led much of my audience to receive TIC training, I couldn’t help but think back to my own training and how the lack of TIC led me to my strong interest in the subject.

I was halfway through my residency in 2014 when the Substance Abuse and Mental Health Services Administration released its landmark guidance on trauma-informed approaches. ¹ My fellow trainees and I routinely obtained urine toxicology screens with prenatal labs and on admission to labor and delivery. There was never any discussion of consent, Fourth Amendment violations, or consequences for family policing ² (also known as Child Protective Services). My complicity with those norms still fills me with shame and regret. Instead of avoiding harm, we were perpetuating it within our over-policed, trauma-overexposed population.

In addition to being the agent of trauma for patients, I also was on the receiving end of the system tasked with educating me. After my most devastating obstetric outcome, I asked for a debrief. I was told we didn’t need to do one, and then my team and I were publicly berated for our clinical decision-making. I felt abandoned and lost faith in my program. As I progressed through the residency and then fellowship, I noted that faculty’s empathy toward trainees seemed to have a bimodal distribution with peaks at “I got through it, so suck it up” and “I struggled through it, and it shouldn’t have to be this hard.” I resolved to be on the latter side of the distribution.

As I learned about trauma-informed approaches to medical care and pedagogy, they became critical to my ethos as a clinician-educator. Checking in with learners after bad outcomes and pitching in with “resident” tasks on labor and delivery are two of the ways I try to be trauma-informed with students, residents, and fellows. I would be less effective in modeling TIC with a patient and resident in our exam room if I walked out of that room with my resident and berated them for fumbling with a contraceptive placement. Trauma-informed care and pedagogy need to intertwine, and striving for both makes me feel hopeful about creating safer spaces for patients and learners.

Even as TIC becomes part of more medical schools’ curricula, trauma-informed pedagogical approaches are absent from much of medical education. It’s no wonder that learners’ empathy dwindles throughout their training ³—perhaps that accounts for the bimodal distribution of attendings’ empathy. Even as physicians and clinicians spend more than 2 decades receiving formal education, we may never be taught to teach, let alone taught with or about trauma-informed pedagogical approaches. We can’t expect learners to provide trauma-informed care when they haven’t been exposed to it during their preclinical and clinical years. ⁴

So, who will teach the teachers themselves? Until trauma-informed care and trauma-informed pedagogy are standard within medical education, we will need to seek this knowledge as part of our continuing education. Bringing all of us up to speed on TIC will require integration of trauma-informed approaches in our curricula and larger medical systems. Making TIC the standard of medical care and trauma-informed pedagogy an expectation in medical education may help future clinicians create the trauma-informed systems that were lacking during our own training.