By Dr. Ghazala Radwi, MD, FRCPC
Trauma-informed medical education* (TIME) is a much-needed framework recently proposed by a group of medical students and physicians. TIME includes trauma-informed clinical care, the development of trauma-informed curricula and the creation of trauma-informed learning environments. The focus of this resource is on the latter: cultivating trauma-informed learning environments.
Let’s look at a practical example from my work experience of an interaction where a trauma-informed lens was not applied. I received feedback about a learner who I’ll call Dr. T.** The evaluation mentioned that Dr. T was “overconfident” and did not seem interested in integrating constructive feedback into their learning. The comment section of the evaluation provided numerous examples where Dr. T was “argumentative” or where they disengaged completely in rounds. The evaluator suggested that the rotation be repeated. I met with Dr. T to hear their perspective. Visibly shaken, they shared their experience of relentless questioning during rounds in front of large groups that included residents, nurses and often the patients. They shared how the evaluator’s tone of voice and body language often projected hostility. They said they had tried to explain their perspective several times, but they felt that a fixed opinion of them had been formed early in the rotation. They confided that this evaluation had thrown them into a place of intense self-doubt about their career path in medicine even though they had gone through many life challenges to get to this point in their training. This is an example of a medical learner experiencing a trauma response.
What is trauma?
Dr. Gabor Maté, a Canadian physician and expert in trauma and addiction, defines trauma as a psychological, invisible wound that continues long beyond the initial event and has deep emotional, psychological, neurobiological and physical consequences. The initial event(s) may be a major event, such as a major illness, the death of a loved one or a sexual assault, but could also be a series of less obvious, repeated events. In addition, trauma may be historical, intergenerational or oppression based (i.e., discrimination and violence directed at minority groups within a dominant culture). These categories of trauma may be associated with major negative consequences* for mental health.
The neurobiology of trauma
According to the polyvagal theory, which is the science of safety within the human body and nervous system, and the extensive contributions of Dr. Bessel van der Kolk* in the field of trauma, traumatic memories are stored within the autonomic nervous system as habitual patterns of responding to internal and external triggers of threat or danger. These neurobiological imprints last long beyond the initiating event. If triggered, they can cause the same emotional pain and dysregulation as the original event. Building on these subconscious patterns, a series of coping and adaptive mechanisms may become dominant when an individual feels threatened. The brain and autonomic nervous system operate from a defensive mode rather than a cognitive mode. When in survival mode, learning, judgment and insight are all affected.
So, what had happened with Dr. T? Feedback was given in front of others, and the evaluator’s tone of voice on rounds and choice of words in the evaluation triggered a deeply painful and disempowering emotional response of shame. Dr. T’s responses to the course preceptor were not argumentative behaviour but rather survival driven by an activated sympathetic nervous system that had been shaped by adversity and triggered by feelings of lack of safety. It was not possible for Dr. T. to learn new concepts and the insight necessary to adapt at the neurobiological level. This understanding can be viewed in contrast to the judgment that the learner was intentionally being difficult and was uninterested in learning, that this was a personality issue or a moral flaw.
Why is a trauma-informed approach necessary in medical education?
Trauma is ubiquitous. The Canadian Longitudinal Study on Aging showed that three in every five Canadian adults aged 45–85 years have been exposed to at least one adverse childhood experience. The prevalence of child abuse in Canada is 32%, and all types of abuse are associated with mental health issues according to a study by Afifi and colleagues published in CMAJ.
A study in the British Journal of Psychiatry explains that childhood adversities are linked to long-term maladaptive psychological consequences that translate into behavioural patterns. These show up as coping or defence mechanisms that an individual has learned over a lifetime as adaptations necessary for survival.
There are several ways in which the learning environments in medicine can induce trauma or trigger pre-existing traumatic responses in learners. As outlined by an article in the Journal of Emergency Medicine, when handling “underperformance,” remediation and “unprofessional” behaviours, the medical culture often evokes shame. Experiencing shame is often an inherent part of the dysregulating experience of trauma. Shame is a deeply distressing, negative global self-appraisal that is associated with feelings of powerlessness and lack of worth. Race- or gender-based discrimination, sexual harassment and bullying are common occurrences within medical learning systems, contributing to hostile, trauma-evoking environments. Lack of safe reporting systems and the power hierarchy add insult to the original injury.
Many individuals with a history of trauma or ongoing trauma require the help of trauma-informed therapists. Unfortunately, medical professionals have been shown to avoid seeking help, especially for psychiatric concerns. Taken altogether, these issues indicate that there is a need to address trauma in medicine by fostering trauma-informed learning environments.
How can trauma-informed learning environments be cultivated?
Establishing trauma-informed learning environments will require concerted efforts by medical educators and organizations. It will also require action by individuals and leaders to promote a healthy medical culture and to allow learners to access the help they need to process and integrate their traumatic experiences and put them on the path of post-traumatic growth. The following concepts are applied through the lens of Trauma-Informed Leadership training.
Medical educators can support learners in the following ways:
- Reflect on your personal history of trauma and seek help if necessary. As leaders, our personal experiences show up in how we relate to the world.
- Notice your personal biases. A rotation evaluation often becomes a global assessment about the learner’s personality and character and may contribute to the shame that medical learners feel when “underperforming.” Replace judgment with compassionate curiosity.
- Understand how trauma shapes the nervous system. Learning, judgment and insight can be deeply affected, especially in environments that do not promote psychological safety.
- Recognize signs of lack of safety. Confrontational behaviour and disengagement may be signs that a learner is experiencing emotional distress and lack of safety. Check in with the learner in a safe setting that allows for confidentiality.
- Encourage and normalize the use of mental health services offered by provincial physician health programs. Additionally, be aware of what resources are available locally and make them known to learners.
- Promote peer support. Designated students or residents can be trained in trauma-informed concepts.
Leaders can promote healthy medical culture in the following ways:
- Demonstrate vulnerability and share stories. You can role model a culture that places value on asking for help and views it as strength.
- Create platforms for openly discussing shame in medical culture. The damaging effects of shame can be mitigated in an environment of acknowledgment and empathy.
- Challenge learning styles and program cultures where hostile, harsh learning environments are believed to be instrumental in creating “resilient” physicians capable of performing well under stress.
Organizations can increase trauma awareness in the following ways:
- Sponsor designated individuals within departments to get trauma-informed training. These individuals can influence culture within the organization at many levels.
- Increase awareness of the impact of oppression-based trauma and racism, including intergenerational trauma. Racism often occurs at the level of microaggressions and can contribute to complex trauma manifestations such as PTSD*.
- Hire individuals who bring a trauma-informed lens or add it as a competency in key roles that pertain to learners. Examples of such roles are program directors and wellness officers.
- Create safe systems for reporting and addressing harassment, discrimination and bullying.
What became of Dr. T? I reached out to Dr. T and provided a confidential, open space to discuss trauma and shame. I had the opportunity to share from my personal experience, and this mitigated Dr.T’s feelings of shame and isolation and created space for growth. Dr. T went on to seek professional assistance. This helped them to access post-traumatic growth by allowing them space to integrate the experience and address historical trauma. After a short break, Dr. T was able to complete the remainder of their training at a high level of functioning. At the organizational level, this incident created opportunities for increasing trauma awareness among faculty as well as looking with a critical lens into how teaching and feedback happen in real time in health care settings.
Being trauma informed is not a performative item on a well-being checklist. Trauma informed is a lens through which we choose to view our learners and colleagues, with compassion and deep recognition of how trauma and adversity shape most, if not all, of us.
*Note: This article must be purchased or rented.
**While the described incident is an aggregate of actual occurrences, details have been modified and names changed to protect the identities of those involved.
Are you in distress? Get help now.