Navigating the Roadmap for Trauma-Informed Medical Education: Application of Undergraduate Medical Education Competencies

Abstract

Background

Trauma is common in the United States, increases risk of long-term adverse health effects, and individuals who experience it often find seeking medical care difficult. Trauma-informed care (TIC) builds trust and fosters healing relationships between clinicians and patients; however medical education has lacked consistent training in TIC. Using recently published competencies for undergraduate medical education (UME), this manuscript provides curricular examples across 8 domains to assist faculty in developing educational content.

Methods

The authors identified published curricula for each of the 8 competency domains using a published search strategy and publicly available database. Inclusion criteria were published works focused on UME in the United States; abstracts and curricula not focused on UME were excluded. The authors used a consensus-based process to review 15 eligible curricula for mapping with the competencies.

Results

Of 15 published UME curricula, 11 met criteria and exemplify each of the 8 UME competency domains. Most of the available curricula fall into the Knowledge for Practice and Patient Care domains. Most were offered in the first 2 years of medical school.

Conclusion

Competency-based medical education for TIC is new, and most current educational offerings are foundational in nature. Additional innovation is needed in the competency domains of Professionalism, Systems-Based Practice, Interprofessional Collaboration, and Personal/Professional Development.

This manuscript offers a set of curricular examples that can be used to aid efforts at implementing TIC competencies in UME; future work must focus on improving assessment methods and developmental sequencing as more students are exposed to TIC principles.

Introduction

Trauma “results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or threatening and has lasting adverse effects on the individual’s functioning and physical, social, emotional, or spiritual well-being.”¹ In the United States, most of the population has experienced one or more traumatic events and/or experienced structural inequities, such as racism, which adversely impact health and health systems.^2,3 Although most recover from traumatic stress, exposure often results in poor health across the lifespan through physiologic changes that result in chronic disease, adverse health behaviors, premature death,^1,4 and reduced quality of life. Trauma also increases risk for psychological disorders, self-injury, and suicide.⁴ Despite the ubiquity of trauma and its known negative health effects, clinicians and health care systems are poorly prepared to practice and deliver care that both mitigates the adverse effects of trauma and fosters healing. Trauma exposure at a young age, with its neurodevelopmental disruptions, may impact interpersonal skills, perception, and problem-solving, and create cognitive deficits that can interfere with engagement in and receipt of health care.^1,4 Traditional health care models can disempower, retraumatize, and adversely impact an individual’s sense of autonomy, choice, and control¹ through, for example, their hurried appointments, use of medical jargon, and the need to disrobe and answer sensitive questions.

Trauma-informed care (TIC) addresses these issues using a strengths-based framework grounded in an understanding of and responsiveness to the impact of experiencing trauma. TIC is based on the understanding that health care often triggers and/or invalidates individuals who have experienced trauma, exacerbating preexisting physical and mental health symptoms, and potentially increasing disengagement from care.^3,5,6 TIC maximizes physical, psychological, and emotional safety in all encounters and creates opportunities to rebuild a sense of control and empowerment while fostering healing through safe and collaborative patient-clinician relationships.¹ A growing body of evidence demonstrates the benefit of TIC as a clinical tool in medicine and framework to promote health care engagement and health equity.³

Despite growing and widespread support for TIC, medical education at all levels lacks comprehensive consideration of the profound impact of trauma and potential benefits of TIC.^3,5,6 Given the pervasiveness of trauma and the challenges of the modern health care environment, students and faculty accrue ongoing traumatic exposures across the continuum of medical education and practice, necessitating trauma-informed adaptations to classroom and clinical environments in addition to widespread curricular reform.⁵ Training can help clinicians address the maladaptive, dysregulated interactions among environment, neurobiology, and behavior that link trauma exposure to health impairments.⁷ Accordingly, students and educators have proposed a framework for trauma-informed medical education,^5,6 calling for the implementation of TIC competencies in undergraduate medical education (UME) as a critical first step in transforming medical education and the physician workforce.

A national task force of medical educators and students developed and validated the first TIC competency set for UME to ensure that prior to residency training, students acquire the foundational knowledge, skills, attitudes, and values to engage in trauma-informed, healing-centered, equitable interactions with their future patients, as well as self- and collective care.⁸ The competencies also address the need to transform learning and practice environments, including their implicit elements or hidden curricula, such as institutional policies and resource allocation as well as the modeling of expected physician behavior.⁸ To validate the competencies, the authors used a modified Delphi process and sought input from medical educators and students, including experts on TIC and individuals with lived experience of trauma. This process has been described previously.⁸ Table 1 provides an overview of the 8 competency domains.

Table 1:

Trauma-informed care competencies summarized

Competency	Examples (learning objectives)
Knowledge for practice	Define concepts such as trauma, resilience, and universal trauma precautions. Describe the epidemiology, vulnerabilities, impact, and manifestations of trauma and how structural and social context, including oppression, stigma, and discrimination, can be traumatic.
Patient care	Demonstrate the ability to apply trauma-informed principles in history gathering, physical examination, decision making, counseling, treatment, and referral.
Practice-based learning and improvement	Describe trauma and resilience literature and potential impact on patient care.
Interpersonal and communication skills	Apply principles of TIC in communication with patients and documentation. Respond to patient disclosure of trauma with empathy, acceptance, validation of patient experience, and compassion.
Professionalism	Describe interpersonal and systemic bias and how they might traumatize patients, colleagues, and staff. Describe strategies to mitigate bias.
Systems-based practice	Identify aspects of the health care system that may not be trauma-informed, and identify potential areas of improvement.
Interprofessional collaboration	Demonstrate words and actions that incorporate trauma-informed principles during team-based care.
Personal and professional development	Describe strategies to prevent and mitigate compassion fatigue, moral injury, vicarious and secondary trauma, and burnout.

Note: This list contains highlights from a larger document, which can be found in Supplemental Digital Appendix 1 at http://links.lww.com/ACADMED/B394⁸

TIC, trauma-informed care.

Although TIC curricular development is still relatively new, and many opportunities for further development exist, evidence exists that TIC skills can be readily taught in multiple formats in UME.^3,5,8 This includes concrete skills that are assessable using well-established evaluation techniques that include standardized patient encounters and objective structured clinical evaluations. Space and time to integrate new curricula into UME are scarce, and support and resources vary widely across institutions. Many medical schools lack formal programs and educator academies to inform competency-based curricular enhancement, further emphasizing the need for a practical demonstration of how to implement competencies. The authors’ goal in this manuscript is to offer examples of published curricula of variable length and format mapped to each competency to promote and facilitate inclusion of TIC at the UME level.

Methods

A subgroup of 3 authors from the original competency task force⁸ convened to identify exemplar curricula that map to the UME competencies, with the goal of illustrating the practical application of competency-based medical education for TIC. Inclusion criteria were publication in English, and US-based UME curricula focused on teaching trauma-informed principles. Curricula not focused on UME were excluded. Manuscripts that focused primarily on identification and response to a discrete form of violence or trauma (for example curricula addressing intimate partner violence or racism) were not included unless they explicitly taught a TIC framework. Published curricula were identified through review of a recent scoping review³ and publicly available resource guide.⁹ Of 9 total UME curricula identified, 4 were removed. To identify content that was missed or published recently, one author (MRG) did an additional literature search using the same search phrases utilized by Burns et al³ restricting selections to UME. This additional search identified 5 additional publications in years 2022–23.^10–14 This search strategy did not identify UME curricula for one domain, Personal and Professional Development, so the additional terms “education, medical, undergraduate, curriculum, well-being, trauma” were utilized; this identified one curriculum.¹⁵ When curricula had similar learning objectives, the authors selected the study with the most robust evaluation strategy. Their group used a consensus-based process to review the curricula that met inclusion criteria and to match, or map, them to the 8 competency domains.

Although many graduate medical education–level TIC curricula may prove relevant and applicable in the UME setting, the authors did not include them in this brief UME-focused manuscript. They also chose not to include abstracts and poster presentations as they often illustrate work in progress. After applying this strategy, 11 publications remained out of an initial 15 identified. The Albany Medical College Institutional Review Board determined this project does not require further review or approval by the Institutional Review Board.

Results

Table 2 maps the 11 selected curricula to the 8 competency domains. The table includes the year in which curricular content was delivered (M1, M2, etc) as well as a description of the curricular phase (ie, preclerkship, core clerkship, advanced clerkship) as not all institutions’ instructional years correspond to one another. Most published curricula were implemented at earlier curricular phases. The Knowledge for Practice domain had the largest number of mapped curricula. Several published curricula on adverse childhood experiences and TIC exist; however, the authors chose to include that of Pletcher et al,¹⁶ who presented evaluation data from 3 consecutive academic years and 535 students.

Table 2:

Curricular examples by competency domain

Competency	Author/focus	Training level/ curricular phase	Mode/length	Evaluation method	Educational objectives	Primary outcomes
Knowledge for practice	Chokshi17: connection between trauma and health and TIC principles	M2 (preclerkship)	One 4-h symposium: 3 mini-lectures plus interactive small group sessions, integrated into Patients, Populations, and Systems course	Survey, qualitative reflection question	1. Define trauma and the connection between trauma, childhood adversity, and health. 2. Describe the importance and components of a trauma-informed approach to care. 3. Recognize how to address the health effects of trauma exposure for individual patients and within health systems. 4. Practice employing a trauma-informed approach to patient care.	Overall rating of the TIC symposium was 4 out of 5. Strengths included integration of a small group case with discussion on application of TIC in practice, experience of the lecturers and small group facilitators, and review of research relating adversity to specific health outcomes. Content analysis of student reflections mapped to the domains of physician competency.
	Pletcher16: ACEs science, TIC best practices	M1 (longitudinal across preclerkship)	One 3-h didactic followed by small group, case-based discussions, integrated into Health Equity and Social Justice course	Online quiz, course evaluation, focus groups	1. Describe the physical and mental health consequences of ACEs. 2. Discuss the use of the ACE survey in the medical home and how this may assist physicians to better engage and care for their patients. 3. Discuss the impact of resilience on mitigating the negative health consequences of ACEs. 4. Decribe how TIC can benefit patients.	89% agreed to a great or considerable degree that they had gained a deeper understanding of the health effects of ACEs, 82% felt more comfortable asking about ACEs in clinical care, and 82% felt that additional training on this topic would be beneficial to their learning to become doctors.
Patient care	Lee10: TIC principles and application in acute care settings	M1–M4 (students in preclerkship, core clerkship and advanced clerkship); volunteer sample	Didactic lecture, 3 simulation cases	Pre- and postparticipation surveys including Likert scales and free-response questions	1. Identify the importance of incorporating TIC into clinical practice as a universal precaution in the acute care setting. 2. Identify clinical situations in which performing safety screenings for trauma history is indicated in the acute care setting. 3. Improve comfort in using TIC principles during a physical examination in an acute care setting. 4. Increase confidence when responding to colleagues through bystander intervention using TIC principles.	Self-assessed confidence improved across multiple domains, including identifying situations for trauma screenings, inquiring about trauma, and responding as a bystander. Learners felt more familiar with TIC-specific history-taking and physical examination skills. Simulation was perceived as a beneficial educational tool.
	Elisseou18: trauma-informed physical examination	M1 (preclerkship and faculty)	Large group lecture with standardized patient, small group skills sessions, part of clinical skills course	5-point scales were used to evaluate knowledge gained and satisfaction with session	1. Define trauma and TIC. 2. Describe key principles of performing a physical examination in a manner that is sensitive to all patients, particularly those with a history of trauma. 3. List specific examples of trauma-informed language and behaviors that can be utilized during the physical examination. 4. Practice taking vital signs using a trauma-informed approach.	Overall satisfaction with the session was rated as 4.08 (SD = 0.81), and students felt that the session was highly effective in defining a trauma-informed physical examination (4.29, SD = 0.70).
	Elisseou11: trauma-informed peer physical examination	M1 (preclerkship)	Peer PE sessions in fall and spring of doctoring clinical skills course	Pre- and post–student surveys about perceptions of safety, trust, and autonomy	1. Define trauma and TIC. 2. Explain the relevance of a trauma-informed approach to peer physical examination. 3. Identify key principles of performing a trauma-informed physical examination. 4. Describe how trauma-informed language and behaviors can be used throughout the physical examination for both patients and peers. 5. List potential modifications and alternatives to peer physical examination.	Familiarity with TIC principles rose significantly, although overall rating of the experience did not change. Thematic analysis of qualitative data highlighted students’ desire for earlier and increased inclusion of TIC principles in the curriculum.
Practice-based learning and improvement	Hollis12: TIC elective	M1 (preclerkship)	Semester elective: interprofessional didactic lectures, community members, oral presentation on best practices/lessons learned; 14 1-h classes	Combination of anonymous pre- and retrospective pre-/postquestionnaires based on objectives	1. Educate students about the effects of trauma on physical and behavioral health. 2. Familiarize students with TIC skills to incorporate into patient care.	Significant increase in students’ rating of knowledge regarding impact of trauma on health, more comfortable screening for intimate partner violence, performing a physical examination for patients experiencing intimate partner violence, accessing resources for patients experiencing addiction, and caring for patients who have had adverse childhood experiences.
Interpersonal and communication skills	Brown19: screening for and inquiring about trauma and responding to disclosures of trauma	MS1 and dental students (preclerkship)	3.5-h session: live patient interview demonstration, small group discussion sessions and case-based role-plays	Before/after surveys, 5 mo follow-up surveys	1. Define trauma and explain its prevalence and health impacts. 2. Describe the 6 principles of TIC as defined by the Substance Abuse and Mental Health Services Administration. 3. Demonstrate a trauma-informed approach to patient history. 4. Screen for and inquire about trauma, including intimate partner violence, using open-ended questions or a validated screening tool, and respond appropriately to disclosures of trauma using TIC principles.	More than one-third (34%) of respondents reported having received at least one disclosure of trauma from a patient within the first 5 mo of medical school. Students’ comfort with screening for trauma increased from 30% to 56%, and their comfort with responding to disclosure of trauma increased from 35% to 55%. These improvements persisted on reevaluation at 5 mo.
Professionalism	Black13: interactive case-based workshop on responding to bias in the clinical setting, how to avoid/dismantle institutional and racial trauma in clinical settings	PA, APRN, MD (M2/M3) students (preclerkship, core clerkship)	2-h virtual session, part of interprofessional longitudinal clinical experience	Feedback solicited in the form of free-text prompts	1. Teach students basic concepts of TIC. 2. Provide students with sample language and behavior that would allow them to practice TIC with patients in all their clinical experiences.	Learners noted that the lecture provided important insight into and a platform for a topic that has otherwise not been explicitly discussed in their education. Learners also found the presentation engaging and felt the interactive aspects, although limited by Zoom, still allowed for open dialogue with presenters. Feedback indicated that learners wanted more case examples demonstrating the functional application of these tools, especially in relation to their preclinical exposures.
	Goldstein7: trauma knowledge, culturally sensitive assessments, trauma inquiry, trauma-informed response to disclosures	M1, M2 (preclerkship)	6 h of training at Race and Health Summer Institute; included lectures, discussion, and role-play practice	5 open-ended qualitative questions	1. Understand trauma prevalence. 2. Understand ACEs’ and trauma’s impact on mental and physical health and how they affect behavior. 3. Gain a foundation on how to provide TIC in practice.	Qualitative responses: knowledge, recognition, and understanding of trauma’s impact; ability to establish patient safety; and increased confidence and comfort to discuss trauma with patients. A primary skill that respondents reported having acquired from the training was how to ask about trauma.
Systems-based practice	Brennan14: HT training session to educate medical students on recognizing HT red flags and providing TIC to HT survivors; focus on where the system misses survivors	M4 (advanced clerkship)	2-h virtual session, faculty, and community experts, lectures plus small group discussion, part of transition to residency program	Pre- and postsession surveys	1. Discuss the prevalence of HT and the associated vulnerability factors. 2. Identify the major red flags of HT in a clinical setting. 3. Establish comfort in asking appropriate screening questions to identify HT. 4. Respond with increased confidence to HT disclosures using trauma-informed practices (including use of appropriate language). 5. Describe medical care options, safety planning, and state-mandated reporting guidelines in the context of HT.	Significant improvement in all the metrics assessed: awareness, comfort with screening, confidence, ability to safety plan, and knowledge about resources.
Interprofessional collaboration	Black13: as above, curriculum focused on interdisciplinary team	PA, APRN, MD (M2/M3) students (preclerkship)	Virtual session	Feedback solicited in the form of free-text prompts	1. Teach students basic concepts of TIC. 2. Provide students with sample language and behavior that would allow them to practice TIC with patients in all their clinical experiences. 3. Prepare early health professional students to function effectively in the team-based clinical environment.	Outcomes described above under “Professionalism.” All outcomes represent findings from an interprofessional cohort of learners.
Personal and professional development	Ferguson15: curriculum to foster well-being of medical students	MS1, MS2 (preclerkship)	2-y curriculum, 7 didactic sessions, 6 facilitated small group sessions integrated into early clinical learning course (REACH)	Midcurriculum survey and a postcurriculum survey included closed questions (5- to 6-point Likert-type response options) and open-ended questions	1. Appreciate the connection between individual well-being and the quality and safety of the care provided by physicians and trainees to patients. 2. Learn the core concepts and practical skills that allow sustained work with suffering people. 3. Contribute to the cultivation of an equitable, inclusive, and hopeful institutional culture that supports all students to thrive.	Respondents identified skills that the REACH curriculum helped them develop: self-care (84% [85/101]), mindfulness (76% [76/101]), and help-seeking (71% [72/101]). Respondents reported that REACH helped them develop connections with faculty and others different from themselves (71% [72/101]), confidence about tackling unfamiliar problems (67% [67/101]), and connections with other students (65% [65/101]). Only a few (3% [4/101]) indicated that “nothing” from the REACH curriculum helped them.

ACE, adverse childhood experience; APRN, advanced practice registered nurse; HT, human trafficking; MD, medical doctor; PA, physician assistant; PE, professional education; REACH, responsibility, empowerment, aspiration, citizenship, honesty; SD, standard deviation; TIC, trauma-informed care.

Across all competency domains, most curricula offered a single session of varying length; 3 were delivered virtually. Most of the in-person sessions combined a didactic format with small group, case-based sessions and/or simulations (Table 2). Most of the evaluations were before/after surveys, and only Brown et al¹⁹ reassessed longitudinal sustainment of knowledge. Most reports were from a single academic year evaluation, except for 2.^15,16 Finally, most published curricula are geared toward foundational knowledge and typically delivered in the preclinical/preclerkship phase of medical education.

Discussion

Trauma is a near-universal experience and a cause of lifelong poor health. Nevertheless, trauma and adversity are not distributed equally in society, and any effort to mitigate health disparities must include recognition of the ways that traditional health care delivery models disempower and retraumatize vulnerable individuals.

Trauma is common among health care professionals and trainees and often increases, or is amplified, during training. One way to transform the health care experience is to equip all clinicians to engage in TIC with curricular content that begins in the preclerkship years to normalize dialogue about trauma among trainees and clinicians.³ Curricula that consider the intersections of diversity, equity, and inclusion with TIC are notably lacking in the current literature but critical to creating healing in health care environments.³ Direct as well as vicarious workplace trauma, compassion fatigue, and burnout are on the rise for health care workers; thus, efforts that equip future physicians to recognize their own and their patients’ trauma responses and develop skills to address them are critical.²⁰

At the current time, most published curricula address the Knowledge for Practice and Patient Care competencies; the authors hope that widespread dissemination of the competencies will inspire innovation in other domains.³ Specifically, more work is needed in the competency domains of Professionalism, Systems-Based Practice, Interprofessional Collaboration, and Personal/Professional Development. The authors’ observation that most curricula they studied have been implemented early on in training points to a need to expand from foundational to more advanced instruction that is developmentally sequenced across the UME trajectory. However, in settings where TIC instruction has not been introduced early on, foundational content may still be meaningful and effective for more advanced medical students. This will also hold true when delivering curricula for residents and faculty; those who lack prior exposure to TIC may benefit from basic instruction. Finally, each medical school sequences its curricular transitions differently, so the optimal placement of TIC content may vary from one school to another.

Published TIC curricular assessments have focused predominantly on knowledge-based self-assessments rather than objective skills-based assessments, underscoring the need for more robust TIC assessment criteria and rubrics. Moreover, formal faculty development is essential as many educators have not yet received training in TIC.^3,5,6 One efficient way to accomplish this is by training facilitators using the same competency-based curricula developed for learners⁵; this content can be delivered simultaneously.¹⁸ Faculty development efforts can address both foundational TIC knowledge and skills and empower faculty to apply a trauma-informed lens to the learning context.²¹ Berman et al recommend following a systematic process to engage all stakeholders—leadership, faculty, students, and staff—in the design, implementation, and assessment of developmentally sequenced TIC instructional materials across the UME trajectory (Figure).⁸ Whenever possible, synergy should be sought with curricular content on social determinants of health, antiracism, and structural competency.^3,8

Figure:

Implementation of trauma-informed care competencies: roles and suggested activities.^8,21 DEI = diversity, equity, and inclusion; TIC = trauma-informed care.

This brief report has several limitations. Many of the curricula cited were developed and published prior to the development and dissemination of the TIC competencies. By restricting examples to published UME curricula, the authors may have missed unpublished offerings that could provide relevant examples. Similarly, restricting the manuscript scope to UME may have eliminated graduate medical education content that satisfies the competencies and could be adapted to UME settings. Finally, the process the authors used to select and categorize curricula may have been prone to bias. Nevertheless, they believe that this report will provide a valuable toolkit for TIC competency implementation.

Next steps for universally implementing TIC competencies throughout UME include widespread dissemination of this work and advocacy on the part of students, medical educators/faculty, and curriculum deans.^8,21 Improving the quality of assessments and providing longitudinal data on learning and patient care outcomes will also be critical. Competency-based TIC curricula delivered in UME will catalyze content development and transformation in residency training, faculty development, and continuing medical education.

Conclusion

This manuscript offers a set of concrete curricular examples that can be used to facilitate the implementation of TIC competencies in UME and elucidates gaps in existing validated curricula by competency domain, outlining areas for opportunity, growth, and scholarship. Implementing TIC curricular content at the UME level is a critical way to transform health care through enabling future physicians to engage in care that promotes safety, healing, and equity.