Roadmap for Trauma-Informed Medical Education: Introducing an Essential Competency Set

Survey of OB/GYN Residents Knowledge and Practice of Trauma Informed Care

BACKGROUND

There is a high prevalence of a history of traumatic experiences among those seeking obstetric/gynecologic care. OB/GYN clinicians must use trauma-informed care practices to avoid re-traumatization and to provide supportive care. The objective of this study was to describe the knowledge and use of trauma-informed care practices by OB/GYN residents in the outpatient setting.

METHODS

A descriptive research design was used. In February 2022, an email with a link to an electronic survey was sent to US OB/GYN residency program directors via a listserv. OB/GYN program directors were asked to forward the survey to residents in their program. The survey included closed-response questions, some of which were Likert scale, to assess the frequency of use of certain trauma-informed care practices during the provision of pelvic examinations.

RESULTS

Seventy US OB/GYN residents responded to the survey. Only half of residents surveyed reported that they practiced trauma-informed care and half reported either not receiving education or were not sure if they had training on the subject. Additionally, half of the respondents were unaware of the ACOG Committee Opinion 825: Care of Patients with History of Trauma.

CONCLUSION

There was limited use of trauma-informed care practices among OB/GYN residents in this study. Considering the high prevalence of traumatic experiences among individuals seeking gynecologic care, a framework for trauma-informed pelvic exams should be included in the residency curriculum and applied universally.

Best Practices for the Gastroenterologist: Trauma-Informed Care in the Endoscopy Suite

Trauma is a risk factor for several gastrointestinal illnesses, especially disorders related to the gut-brain axis. Gastroenterology (GI) care environments, particularly endoscopy units, put patients at risk of unintentional re-traumatization due to the sensitive nature of the questions, examinations, and procedures. Trauma-informed care has six pillars outlined by the Substance Abuse and Mental Health Services Administration: safety, trustworthiness and transparency, peer support, collaboration and mutuality, empowerment voice and choice, and cultural historical and gender issues. Adopting these pillars for trauma-informed GI care can transform the patient and staff experience. Traumatic or potentially traumatic experiences are common, and therefore a universal trauma precautions approach is useful in a busy GI environment. There are considerations for each of the pre-, peri-, and post-procedural settings that are simple to implement, which can increase the sense of safety, trust, and autonomy for each patient in the endoscopy suite.

Incorporation of Trauma-Informed Care Into Entrustable Professional Activities for Medical Student Assessment

PROBLEM

Trauma-informed care (TIC) provides a medical framework for addressing and mitigating the negative consequences of trauma. In response to student and faculty advocacy, medical schools are developing trauma-informed curricular content. However, medical education literature does not present a comprehensive assessment rubric to evaluate medical students' acquisition of trauma-informed clinical skills.

APPROACH

A committee of medical students, trainees, and faculty developed a longitudinal TIC curricular theme at Harvard Medical School (HMS). Guided by the National Collaborative on Trauma-Informed Health Care Education and Research competencies, the committee created a set of medical student TIC competencies from July to December 2019. From November 2021 to November 2022, 3 committee subgroups generated new TIC descriptors for each HMS entrustable professional activity (EPA), then circulated these to other subgroups, external experts, and stakeholders for review and feedback. From April to June 2023, the committee iteratively reviewed the materials until reaching consensus for content and pedagogy. The committee integrated TIC content into HMS's existing EPAs expected of students, provided anchoring descriptions of each level, and achieved consensus using a process of iterative review with TIC content experts.

OUTCOMES

The committee identified 10 TIC competencies and revised all 13 general HMS EPAs to include specific items based on these competencies. The committee incorporated at least 1 trauma-informed competency into each HMS EPA.

NEXT STEPS

This novel set of HMS EPAs provides a framework for assessment of TIC clinical skills. Faculty will be trained to correctly and reliably incorporate TIC competencies into patient care and to use the TIC-inclusive EPAs for student assessment, ensuring that TIC is standard medical practice at HMS. This work may facilitate the adoption of trauma-inclusive EPAs by other institutions to educate the next generation of physicians to practice TIC and thus promote a more accessible, safe, and equitable health care system.

How medical students' trauma histories affect their clinical clerkship experiences

BACKGROUND

As the gender demographics of medical students have evolved over the past decades, it is important to understand potential stressors and challenges that may affect clinical learning experiences. This study investigated the prevalence of prior sexual assault (SA) and interpersonal violence (IPV) in medical students and how these affect their clinical clerkship experiences.

METHODS

A survey was distributed to third- and fourth-year medical students at a single institution in August 2022 querying respondents on demographics and prior experiences with SA/IPV at any point in their lives. Respondents who indicated they had previously experienced SA/IPV were directed to questions about how these experiences affected clerkships.

FINDINGS

Of 419 students, 125 responded to the survey (30.8% response rate). Forty (31.1%) reported a history of SA/IPV-32 (80.0%) women, five (12.5%) men, and three (7.5%) who did not report gender or identified as non-binary. Of the 40 respondents with a history of SA/IPV, 20 (50.0%) reported that their prior history affected their overall clinical experience, and nine (22.5%) felt that it affected their performance. Only seven (17.5%) reported using any resources, such as counselling, during their clerkships. Narrative responses discussed significant effects on performing physical exams, taking a history, interacting with team members, and engaging during clerkships.

DISCUSSION

This work demonstrates the high number of students affected by SA/IPV and how these prior experiences affected core components of their clerkship experiences.

CONCLUSIONS

Institutions must be proactive to create better supports for learners with histories of trauma, including SA/IPV.

Trauma-Informed Undergraduate Medical Education: A Pathway to Flourishing with Adversity by Enhancing Psychological Safety

We describe the Life Experiences Curriculum (LEC), which attempts to integrate medical student well-being with trauma-informed medical education. The long-term goal of LEC is to help medical students flourish with adversity and trauma, where flourishing refers to having a sense of purpose that arises from awareness of one's strengths and limitations, shaped by life experiences. The short-term goal of LEC is to develop students' relational capacities, such as acceptance and awareness of self and others, while building and maintaining students' psychological safety. We describe the conceptual rationale for these goals and the curriculum's development, implementation, evaluation, and limitations. The curriculum extends over four years and involves a preclinical seminar and students' individual and group reflection sessions with LEC faculty. The seminar addresses the coexistence of trauma and flourishing across life experiences, as well as how safety in relationships is impaired by traumatic experiences and must be restored for healing and growth. The physician faculty have no role in student evaluation and co-lead all LEC activities. LEC is intended to provide students with new language for understanding the process of trauma and flourishing in both individuals and systems and to build and sustain students' relational capacities. There are ongoing efforts to re-imagine self-care as communal-care in which care and support are given and received in a community of students and faculty. Such a model may help build the relational capacities needed to deliver trauma-informed care and also promote flourishing with adversity in healers and in those seeking to be healed.

Integrating Psychological Care Training in Trauma Care for Medical Students: the Need and the Strategies

Trauma, whether arising from accidents, violence, or medical emergencies, generally has a substantial impact on the lives of victims, their family members, the society, and the healthcare delivery system. The purpose of the article is to justify the need to train medical students in trauma-related psychological care, explore the significance of simulation-based training, and identify coping strategies to augment the resilience of medical students. As healthcare professionals are the ones who are executing trauma care-related interventions, it is essential that medical students are trained to offer psychological care to the victims and family members of trauma to enable healing of both the body and the mind. If medical students learn about psychological care pertaining to trauma, they will be well equipped to handle sudden traumatic events by being more adaptable and resilient. Medical students can be trained in multiple ways to improve their psychological preparedness while delivering trauma care. As a part of the psychological training related to the management of trauma victims, medical students must be trained in developing coping strategies and resilience. In conclusion, facilitating learning among medical students in the psychological aspects of trauma care is a crucial domain for developing competent healthcare professionals. It is a priority to integrate into medical education a comprehensive learning about psychological care that will empower medical students to respond effectively to the complexities of trauma with empathy, resilience, and effective communication.

Competencies for Those Who Coach Physicians: A Modified Delphi Study

The rapidly evolving coaching profession has permeated the health care industry and is gaining ground as a viable solution for addressing physician burnout, turnover, and leadership crises that plague the industry. Although various coach credentialing bodies are established, the profession has no standardized competencies for physician coaching as a specialty practice area, creating a market of aspiring coaches with varying degrees of expertise. To address this gap, we employed a modified Delphi approach to arrive at expert consensus on competencies necessary for coaching physicians and physician leaders. Informed by the National Board of Medical Examiners' practice of rapid blueprinting, a group of 11 expert physician coaches generated an initial list of key thematic areas and specific competencies within them. The competency document was then distributed for agreement rating and comment to over 100 stakeholders involved in physician coaching. Our consensus threshold was defined at 70% agreement, and actual responses ranged from 80.5% to 95.6% agreement. Comments were discussed and addressed by 3 members of the original group, resulting in a final model of 129 specific competencies in the following areas: (1) physician-specific coaching, (2) understanding physician and health care context, culture, and career span, (3) coaching theory and science, (4) diversity, equity, inclusion, and other social dynamics, (5) well-being and burnout, and (6) physician leadership. This consensus on physician coaching competencies represents a critical step toward establishing standards that inform coach education, training, and certification programs, as well as guide the selection of coaches and evaluation of coaching in health care settings.

U.S. Physicians' Training and Experience in Providing Trauma-Informed Care in Clinical Settings

Trauma-informed care (TIC) is a comprehensive approach that focuses on the whole individual. It acknowledges the experiences and symptoms of trauma and their impact on health. TIC prioritizes physical and emotional safety through a relationship of trust that supports patient choice and empowerment. It provides a safe and respectful healing environment that considers specific needs while promoting a greater sense of well-being, patient engagement, and partnership in the treatment process. Given the prevalence of trauma, this descriptive cross-sectional study examined the attitudes and perspectives of U.S. physicians (N = 179; 67% males; 84% White; 43% aged 56-65) in providing trauma-informed care using an anonymous 29-item online survey administered by Reaction Data. Findings showed that 16% (n = 18) of physicians estimated that >50% of their patients have a history of trauma. Commonly perceived barriers to providing TIC were resource/time/administrative constraints, provider stress, limited awareness of the right provider to refer patients who experienced trauma, and inadequate TIC emphasis in medical education/training. Expanding physicians' knowledge base of trauma through training and organizational policy/support is crucial in enhancing their TIC competence, particularly in caring for patients with complex care needs whose social determinants increase their risk of exposure to adverse experiences that carry lasting physical and psychological effects.

Effects of Adverse Childhood Experiences in Black Older Adults

Adverse childhood experiences (ACEs) are socially complex events that affect children early in their lives. Research indicates that experiencing multiple ACEs increases an individual's risk for chronic physical and mental illness and premature death. Multigenerational traumas, including slavery, segregation, and institutional racism, have created an environment that perpetuates social and economic inequalities, ultimately leading to an increased risk of ACEs in Black individuals. ACEs' effects can manifest in Black older adults as physical health problems and mental health and social issues. Addressing the disparities in ACEs among Black older adults requires a multifaceted approach. Culturally sensitive and trauma-informed approaches are vital in supporting the mental and physical health of Black older adults who experienced ACEs. Clinicians, researchers, and policymakers need to advocate for supportive policies and interventions that address systemic racism, promote economic opportunities, and ensure equitable access to resources. [Journal of Psychosocial Nursing and Mental Health Services, 62(2), 9-12.].

Measuring wellbeing: A scoping review of metrics and studies measuring medical student wellbeing across multiple timepoints

PURPOSE

Studies have demonstrated poor mental health in medical students. However, there is wide variation in study design and metric use, impairing comparability. The authors aimed to examine the metrics and methods used to measure medical student wellbeing across multiple timepoints and identify where guidance is necessary.

METHODS

Five databases were searched between May and June 2021 for studies using survey-based metrics among medical students at multiple timepoints. Screening and data extraction were done independently by two reviewers. Data regarding the manuscript, methodology, and metrics were analyzed.

RESULTS

221 studies were included, with 109 observational and 112 interventional studies. There were limited studies (15.4%) focused on clinical students. Stress management interventions were the most common (40.2%). Few (3.57%) interventional studies followed participants longer than 12 months, and 38.4% had no control group. There were 140 unique metrics measuring 13 constructs. 52.1% of metrics were used only once.

CONCLUSIONS

Unique guidance is needed to address gaps in study design as well as unique challenges surrounding medical student wellbeing surveys. Metric use is highly variable and future research is necessary to identify metrics specifically validated in medical student samples that reflect the diversity of today's students.

A trauma-informed approach to suicide prevention for the COVID-19 pandemic

During the COVID-19 pandemic, researchers have questioned how the devastation of the pandemic might impact suicide rates. While initial evidence on suicide rates during the early stages of the pandemic is mixed, there are signs we should still remain vigilant. One way of conceptualizing the long-term effects of the pandemic is as a source of multiple traumatic events: the collective trauma of widespread illness and death and social upheaval, individual traumas from the virus itself (e.g., serious illness and disability, traumatic grief, vicarious trauma), traumas from the social and economic consequences (e.g., domestic violence, unemployment), and its intersections with pre-pandemic traumas and oppression. Given trauma is a well-established risk factor for suicide, this carries significant implications for suicide prevention in the wake of the pandemic. Yet access to trauma-informed care, education, and research remains limited. The pandemic presents a unique opportunity to address these gaps and implement a trauma-informed approach to suicide prevention. Building on existing frameworks, we describe how effective suicide prevention for the pandemic must incorporate trauma-informed and trauma-specific services, strategies, and policies; capacity building; collaborative research; and knowledge exchange. Attending to the traumatic effects of the pandemic may reduce the long-term impact on suicide rates.

Trauma-Informed Care: A Missing Link in Addressing Burnout

The Covid-19 pandemic and national movements for health equity have highlighted the impact of trauma on public health as well as on health worker well-being. As burnout rates across healthcare climb, we seek creative and effective solutions. Current anti-burnout strategies focus on much needed systems solutions for employee success; however, they often lack a trauma-informed approach. Trauma is highly prevalent in society at large, and health workers are further exposed to trauma in the course of their professional studies and duties. Common symptoms of burnout may actually be manifestations of traumatic stress. Trauma-informed care (TIC) is a strategic framework and growing social movement for providing quality care to survivors of individual, interpersonal, collective, and structural trauma. Importantly, TIC has practical applications to address our healthcare burnout epidemic. In this perspective piece, an expert describes a trauma-informed lens through which to view burnout solutions using SAMHSA's 4 Rs of a trauma-informed approach: 1) Realize the widespread impact of trauma, 2) Recognize the signs and symptoms in patients and staff, 3) Respond by integrating knowledge about trauma into practice, and actively 4) Resist re-traumatization. Moving forward, key stakeholders must collaborate to build and refurbish efficient systems alongside a trauma-informed organizational model. TIC can transform the healthcare experience for patients and employees alike by fostering community, empowerment, and healing.