On Triggering and Being Triggered: Civil Society and Building Brave Spaces in Medical Education

Changing Policy for Inclusion: Peer-to-Peer Physical Exam Practice in Medical School

Evidence: Across all U.S. medical schools, trainees spent a median of 59 hours teaching physical examination skills. Of this time, 30% is dedicated to PPE practice. Despite this prevalence, there are data that show some students find this uncomfortable, especially women. Literature on best practices around PPE highlights voluntary participation, informed consent, and an available alternative to learning physical xamination skills. These are not uniformly available in all learning environments. There are little data around the impact of PPE on students who have experienced or are experiencing sexual trauma. Authors have drawn conclusions about the potential for harm given the prevalence of sexual mistreatment in US higher education.

Implications: Our medical school policy required students to participate in PPE practice, undressing for the exams wearing only shorts (and a sports bra for women) an and a hospital gown. Students who could not participate in this practice for reasons ranging from mobility to religious beliefs had to seek individual formal accommodations to be exempt, putting the onus of change on potentially vulnerable individuals. We evaluated the policy around PPE, and concluded that the school's requirements could be harmful and isolating, as they required students to disclose their personal vulnerabilities while seeking exemptions from being examined by peers. At our institution, a group of students instead advocated for the school to review the policy and create a PPE procedure that was safer and more inclusive while supporting student learning. Our experience emphasized the potential for students to advocate for change, while also highlighting the need for greater research in the field of trauma-informed curricular design for medical education.

Trigger warnings in medical student education: A scoping review

BACKGROUND

Medicine is recognised as a challenging course where exposure to potentially distressing content is inevitable. Some educators provide students with warnings before they encounter potentially upsetting content-trigger warnings. In this scoping review, we mapped the existing literature seeking to better understand how trigger warnings are implemented in medical schools and how they are influencing education within them.

METHODS

Bibliographic databases were searched to identify relevant literature, including searching for grey literature. Articles were included if they focussed on medical school education and were written in English. Data analysis was undertaken using both quantitative and qualitative approaches (thematic analysis).

FINDINGS

Searching generated 1284 potential records for inclusion. Articles not related to the primary research question were excluded. Abstracts of the remaining 841 articles were screened, and ultimately, 12 articles met criteria for full-text review. Of these, there were three empirical research studies. Qualitative analysis identified five main themes: purpose, implementation, student distress, responsibility and problems with terminology.

CONCLUSIONS

The use of trigger warnings within medical student education remains contentious. There is a lack of consensus as to their purpose and much diversity in how they are implemented. There was limited published empirical evidence to inform practice in this area.

Equity and justice in medical education: mapping a longitudinal curriculum across 4 years

BACKGROUND

In 2024 in the United States there is an attack on diversity, equity, and inclusion initiatives within education. Politics notwithstanding, medical school curricula that are current and structured to train the next generation of physicians to adhere to our profession's highest values of fairness, humanity, and scientific excellence are of utmost importance to health care quality and innovation worldwide. Whereas the number of anti-racism, diversity, equity, and inclusion (ARDEI) curricular innovations have increased, there is a dearth of published longitudinal health equity curriculum models. In this article, we describe our school's curricular mapping process toward the longitudinal integration of ARDEI learning objectives across 4 years and ultimately creation of an ARDEI medical education program objective (MEPO) domain.

METHODS

Medical students and curricular faculty leaders developed 10 anti-racism learning objectives to create an ARDEI MEPO domain encompassing three ARDEI learning objectives.

RESULTS

A pilot survey indicates that medical students who have experienced this curriculum are aware of the longitudinal nature of the ARDEI curriculum and endorse its effectiveness.

CONCLUSIONS

A longitudinal health equity and justice curriculum with well-defined anti-racist objectives that is (a) based within a supportive learning environment, (b) bolstered by trusted, structured avenues for student feedback and (c) amended with iterative revisions is a promising model to ensure that medical students are equipped to effectively address health inequities and deliver the highest quality of care for all patients.

Embracing Failure: Nurturing Learning and Well-Being in Anesthesiology and Perioperative Medicine

Failure, ubiquitous in life and medical practice, offers myriad opportunities for learning and growth alongside challenges to overall well-being. In this article, we explore the nature of failure, it's sources and impacts in perioperative medicine, and the specific challenges it brings to trainee well-being. With a deeper understanding of the societal, psychological and cognitive determinants and effects of failure, we propose solutions in order to harness the opportunities inherent in failures to create brave and supportive learning environments conducive to both education and well-being.

Twelve tips for implementing trigger or content warnings in healthcare professions education

Trigger warnings are statements offering prior notification of sensitive content, allowing recipients to prepare for and avoid ensuing distress. Students are increasingly reporting expectations for warnings in classrooms and learning contexts. Discussions regarding use of warnings have clear relevance to healthcare education, which regularly explores sensitive content. Their use has been positioned as a measure for inclusive education and as a means to enhance trauma awareness and empathy. Expectations for warnings need to be considered in the context of preparedness for professional practice. This Twelve Tips paper explores the evidence in relation to warnings and its applicability to social learning contexts. These tips highlight considerations and strategies for the use of warnings in the context of healthcare education, balancing issues of inclusivity, learner and educator wellbeing, and professional preparedness. These discussions are situated within the context of current classroom-based healthcare education.

Handle with Care: Transformative Learning as Pedagogy in an Under-Resourced Health Care Context

Issue: A significant component of health professions education is focussed on students' exposure to the social determinants of health and the challenges that patients within the health care system face. An appropriate way to provide such exposure is through distributed clinical training. This usually entails students training in smaller groups along the continuum of care, away from tertiary academic hospitals. This also means students are away from their existing academic and social support systems. It is evident that knowledge and clinical skills alone are not sufficient to prepare students, they also need to be taught to critically reflect on how their own values and attitudes traverse their knowledge and skills to influence their practice as healthcare professionals. This process of critical reflection should aim to provide a transformative learning experience for students and requires active facilitation. In under-resourced health care contexts where clinicians responsible for student training are facing high patient load, lack of resources, inequitable health care services and high levels of burn-out, the facilitation of student learning may be compromised. Evidence: Clinical learning opportunities that are considered transformative, frequently challenge students' sense of self and sense of belonging. This experience can have detrimental effects if the processes of transformative learning pedagogy are not adequately facilitated. The provision of support staff, lecturers and clinical facilitators on the distributed training platform is challenged by the remote nature of some of the sites and the cost of recruiting and capacitating additional on-site staff. The potential for what has been termed "transformative trauma" and the subsequent halted transformative learning experience, has ethical implications in terms of student wellness and the educational responsibility institutions carry. Implications: The authors suggest considerations in facilitating an ethical transformative learning process. These include making the transformative learning pedagogy explicit to students and clinical facilitators and using the 'brave spaces' framework to help students with individuation and provide them with the tools to understand how emotion influences behavior. Strategies to improve relationship development and communities of support, as well as ideas for faculty development are offered.

Challenges facing standardised patients representing equity-deserving groups: Insights from health care educators

INTRODUCTION

Health professions training programmes increasingly rely on standardised patient (SP) programmes to integrate equity-deserving groups into learning and assessment opportunities. However, little is known about the optimal approach, and many SP programmes struggle to meet these growing needs. This study explored insights from health care educators working with SP programmes to deliver curricular content around equity-deserving groups.

METHODS

We interviewed 14 key informants in 2021 who were involved in creating or managing SP-based education. Verbatim transcripts were analysed in an iterative coding process, anchored by qualitative content analysis methodology and informed by two theoretical frameworks: sociologic translation and simulation design. Repeated cycles of data collection and analyses continued until themes could be constructed, aligned with existing theories and grounded in empirical data, with sufficient relevance and robustness to inform educators and curricular leads.

RESULTS

Three themes were constructed: (i) creating safety for SPs paid to be vulnerable, (ii) fidelity as an issue broader than who plays the role and (iii) engaging equity-deserving groups. SP work involving traditionally marginalised groups risk re-traumatization, highlighting the importance of (i) informed consent in recruiting SPs, (ii) separating role portrayal from lived experiences, (iii) adequately preparing learners and facilitators, (iv) creating time-outs and escapes for SPs and (v) building opportunity for de-roling with community support.

CONCLUSIONS

SP programmes are well positioned to be allies and advocates to equity-deserving groups and to collaborate and share governance of the educational development process from its outset. SP programmes can support the delivery of curricular content around equity-deserving groups by advocating with curricular leadership, building relationships with community partners, facilitating co-creation and co-delivery of educational content and building safety into simulation.

Optimizing mentoring relationships with persons from historically marginalized communities through the use of difficult dialogues

Neuropsychology has struggled to recruit and retain trainees and early career professionals from historically marginalized communities (HMC). One of the primary strategies for retaining these individuals, and ensuring their success, is quality mentorship. Effective mentorship for trainees from HMC requires responsive attention to the unique training experiences that emerge from societal forces, such as structural racism and classism. Although not often discussed with mentors, trainees from these groups experience discrimination at substantial rates, which contributes to dissatisfaction, stress, and ultimately elevated attrition. One strategy to reduce attrition involves developing relational mentorship dynamics to encourage explicit conversations about instances of discrimination during training. However, a barrier to nurturing these types of dynamics is the difference in power and privilege across multiple axes in the dyad. Infusing techniques from the Difficult Dialogues framework offers mentors of HMC trainees a tangible route to reducing the impact of differential power, enhancing relational dynamics, and increasing the likelihood of retention in neuropsychology. The objectives of this manuscript are to elucidate the necessity of understanding one's power and privilege in the mentorship dyad by understanding barriers experienced by persons from HMC. This manuscript also outlines specific strategies through the lens of the Difficult Dialogues framework to ameliorate the negative impact of unaddressed differentials of power and privilege in the mentoring of training experiences in clinical neuropsychology. Finally, through the use of anonymized case examples, the manuscript offers effective strategies for responsive, professional development of trainees from HMC to facilitate supportive neuropsychological training experiences.