Evaluating Student and Faculty Perspectives About the Integration of Trauma-Informed Care in Undergraduate Medical Education

Abstract

Background

Trauma-informed care (TIC) provides a framework for understanding and mitigating trauma’s impact on health. Integrating TIC principles into medical school education equips physicians with the skills necessary for delivering compassionate, patient-centered care.

Methods

A survey regarding experiences with TIC education was emailed to medical students and faculty at the University of Oklahoma College of Medicine. Qualitative and standard quantitative analysis of the results was performed.

Results

A significant majority of faculty (83.7%) and students (92.5%) recognized the relevance of TIC to clinical practice. However, only 37.0% of faculty reported incorporating TIC into their teaching. Despite its acknowledged importance, only 20.4% of students felt satisfied with how TIC was taught. On a Likert scale of 1–5, students reported a comfort level of 1–2 for trauma-informed screenings (31.5%) and physical examinations (62.9%). Proposed solutions to increase TIC education included the implementation of longitudinal curricula, workshops, and conversations about trauma when interacting with patients.

Conclusions

TIC is perceived as relevant to medical education and practice among students and faculty. However, its integration into the undergraduate medical education curriculum is sporadic. Although certain courses incorporate TIC, a cohesive teaching approach throughout the curriculum is lacking. There is uncertainty among faculty regarding the definition of TIC and what aspects may be lacking in the curriculum, highlighting a gap in knowledge and application. The intermittent teaching of TIC affects students’ ability to fully understand the impact of trauma in the clinical setting. The authors’ results supported the integration of a more comprehensive TIC education in undergraduate medical curricula.

Introduction

Trauma is a pervasive issue with profound negative impacts on health. The Substance Abuse and Mental Health Services Administration (SAMHSA) ¹ defines trauma as a very distressing event or series of events that adversely impacts a person’s health. Trauma can manifest from experiences such as violence, abuse, loss, or disaster, and it is estimated that up to 89% of the worldwide population has experienced trauma. ² Potentially traumatic events that occur before the age of 18 are referred to as adverse childhood experiences (ACEs), ³ but trauma may occur at any age and impact both short-term and long-term health outcomes. ^4,5 The health implications of trauma manifest in various ways, including increased health risk behaviors, reduced utilization of health care services, variable treatment adherence, and direct health effects mediated by chronic stress. ⁶

In response to these challenges, trauma-informed care (TIC) has emerged as a crucial approach to care that addresses and mitigates the challenges posed by trauma, while promoting healing and recovery. In 2014, SAMHSA proposed a framework for a trauma-informed approach to services across multiple sectors. ⁷ According to this framework, organizations that employ TIC realize the impact of trauma, recognize its signs, respond by integrating this knowledge into their systems and practices, and resist retraumatization. The principles of this approach are safety; trustworthiness and transparency; peer support; collaboration and mutuality; empowerment, voice, and choice; and cultural, historical, and gender issues. The ultimate aims of TIC are to improve health engagement, strengthen patient-clinician relationships, improve patient health outcomes, enhance health care worker well-being, and prevent additional harm.

Incorporating TIC into medical education is essential to equip physicians-in-training to recognize and respond to the impacts of trauma within their patient populations. A 2023 scoping review of TIC curricula in the health professions across multiple disciplines and levels revealed heterogeneous approaches to TIC, with common objectives centering on screening for trauma and responding to disclosures of trauma. ⁸ In addition to highlighting the need for better implementation of TIC, this study also found that there are few interventions that teach about mandated reporting of trauma, documentation of trauma in the medical records, intersectional approaches to TIC, and secondary trauma among those providing direct patient care. Authors also assert that effects of trauma are pervasive across various medical disciplines, and incorporating TIC throughout all phases of medical education could help facilitate better integration of TIC principles into clinical care.

A more recent scoping review of teaching TIC specifically in undergraduate medical education (UME) looked at what is currently being done in medical schools and how it is being evaluated. ^9–11 This study found that most training is still occurring in one or a small number of sessions and lacks longitudinal follow-up to determine if students are using the TIC skills that they have learned with their patients and health care team. The review also found that students particularly valued active learning such as simulation, role plays, and small group discussions, and they felt trainings could improve on inclusivity of varied patient experiences. Additionally, there is a lack of standardized, integrated, longitudinal curriculum throughout all 4 years of medical school.

Information from medical school faculty and clinicians in practice regarding their preparation and attitudes about teaching TIC is also lacking. A recent survey from 2 medical schools found that although the majority of faculty respondents saw relevance in TIC, only 22% fully incorporated it into their work, and 59% identified a need for additional coaching. ¹² Teaching clinicians may not be aware of current TIC principles and may not feel comfortable instructing about or modeling trauma-informed behaviors. This could further hinder medical students’ ability to learn TIC. Although there has been a study to compare nursing students, preceptors, and faculty perspectives on TIC education, similar studies among medical students, preceptors, and faculty are limited. ¹³

The standardization of TIC education is in its early stages, with the first set of validated trauma-informed competencies proposed in 2023 by the National Collaborative on Trauma-Informed Health Care Education and Research. ¹⁴ A roadmap to curricular integration has built upon these competencies and centers on medical school leadership, a faculty–student advisory committee, and sample resources. ¹⁵ The Association of American Medical Colleges has included a link to these competencies on their website under “Additional Competencies and Priorities” as part of their Competency-Based Medical Education page. ¹⁶ Recently, a set of new TIC descriptors for entrustable professional activities at one medical school was developed, and this work could lead the way to more integration after evaluation of outcomes. ¹⁷

This study attempted to identify the implementation and scope of TIC education in a US medical school by comparing the perspectives of both faculty and students on the curriculum, clinical experiences, and general observations of TIC. By examining the knowledge, perceptions, and experiences of those involved in both teaching and learning TIC, the authors hope to help guide curriculum and faculty development for the future of UME.

Methods

Although validated studies assessing practitioners’ perceived competencies in TIC are emerging, data on a standardized survey specific for UME are lacking. Furthermore, the authors wanted to create surveys that could be tailored to both learners and faculty. Therefore, the authors comprised of medical students and faculty with expertise in TIC developed a survey incorporating novel and adapted questions. The survey aimed to assess knowledge about TIC and ACEs, as well as perspectives on the prevalence of trauma, its impact on patient care and practitioner well-being, and overall integration of TIC into medical curricula. Adapted questions were modeled on a TIC survey from the University of Iowa ¹⁸ and a diversity, disparity, and bias working group survey from the University of Oklahoma. These sources were utilized as they contained, respectively, standardized questions relating to TIC or questions evaluating student and faculty perspectives on medical education. The survey included free-response items, percentage range sliders, and 5-point Likert scales. This study received expedited approval from the University of Oklahoma Health Sciences Center institutional review board.

The survey link was emailed to all medical students (years 1–4; n = 673) and faculty (n = 1136) at the University of Oklahoma. Of faculty, there are 93 course directors. Both medical campuses (Oklahoma City [OKC] and Tulsa) were included. Anonymous responses were collected between November 17, 2023, and January 14, 2024. Although the curricula at the 2 campuses are similar, Tulsa students have additional training in early life adversity and health during their multidisciplinary orientation week (School of Community Medicine Institute), simulation training in communication skills on trauma inquiry with adults, and multidisciplinary team training in caring for patients experiencing intimate partner violence or child abuse.

Demographic data collected included medical student level (MS1–4) and campus affiliation (Tulsa/OKC). Faculty respondents were asked about department affiliation, whether they served as a course director, and their educator roles. The surveys also included self-reported estimates of lifetime trauma prevalence among practitioners and patients. Faculty were asked yes/no questions regarding if they addressed 1) impact of trauma on health and 2) TIC in their course(s).

Both faculty and student respondents were also asked about their familiarity, comfort, confidence, and perceived relevance of TIC in the College of Medicine (COM) curriculum. Questions included student and faculty familiarity with ACEs and TIC (Likert scale item with range of 1-not familiar to 5-extremely familiar); student- and faculty- perceived relevance of TIC in curriculum/practice (Likert scale items with range 1-not relevant to 5-extremely relevant); student comfort level with TIC skills including screening for a history of trauma, responding to a trauma disclosure, and performing a trauma-informed physical examination (single Likert scale item with range 1-not comfortable to 5 extremely comfortable); student confidence to perform a trauma-informed physical examination (single item with scale 1-not confident to 5-extremely confident); student satisfaction with COM teaching of impact of trauma on health (single Likert scale item with range 1-extremely dissatisfied to 5-extremely satisfied); and student perceived effectiveness of TIC as addressed by curriculum (single Likert scale item with range 1-very ineffective to 5-very effective). Finally, student respondents were asked yes/no questions about whether they had clinical experiences involving TIC or if they had clinical experiences where TIC would have been beneficial but was not provided (see Supplemental Appendix 1 for full survey).

Free text questions were utilized to ask both faculty and student respondents about aspects of TIC missing from COM curriculum and the impact of the “hidden curriculum,” which is loosely defined as the “learning that occurs by means of informal interactions among students, faculty, and others and/or learning that occurs through organizational, structural, and cultural influences intrinsic to training institutions” on TIC education. ¹⁹ Faculty were asked if they addressed the impact of trauma on health and to describe any curriculum and teaching modality they used to incorporate ACEs and TIC education in their courses. Additionally, faculty were asked to what extent TIC may be relevant to the information presented in their course and within the clinical setting. The survey also asked faculty what aspects of TIC they would like to add to their teaching (see Supplemental Appendix 2 for full survey). Students were asked to report which clerkships have addressed the impact of trauma on health and whether they had experience with TIC outside of the formal curriculum. Students were also prompted to reflect on clinical experiences where TIC was involved and those in which TIC would have been beneficial but was not incorporated.

Quantitative Analysis

Standard frequency analysis was performed in Statistical Package for the Social Sciences Data Analytic Software (Version 28.0.0.0 [190]). Demographic information was reported as the total count for each response. Responses to questions utilizing percent-range scales and 5-point Likert scales were analyzed and reported as percent frequency and/or calculated mean. Student and faculty responses were compared via frequency and mean analysis. OKC and Tulsa student responses were also compared to identify potential differences between the 2 groups.

Qualitative Analysis

Thematic analysis of qualitative responses was initially performed manually by researchers. Subsequently, to enhance validation of the coding themes, responses were independently grouped using Microsoft Copilot artificial intelligence (AI) software. The research team initially reviewed the responses independently and then met to discuss and organize them into preliminary thematic groups. Next, the responses to each question were entered into Microsoft Copilot AI, which generated its own set of thematic groupings. The team then compared the original themes with those generated by the AI and collaboratively made final decisions regarding the thematic categorization.

Results

Sample Characteristics

Demographic information for student and faculty respondents is included in Table 1. Reponses from 54 students and 60 faculty members were collected and analyzed. The overall response rate was 6.3%, with 8.0% for students and 5.3% for faculty. Among student respondents, a little over one-third of the respondents were MS1s, about one-third were MS2s, and MS3 and MS4s represented a little under 20% each. Only 18% of total students each year are on the Tulsa campus, with the remainder on the OKC campus. Overall, a higher percentage of Tulsa students responded than OKC students.

Table 1:

Demographic information for student and faculty survey responses

Student results (N = 54)
Status, 23–24 academic year	n	%
First-year student	19	35.2
Second-year student	16	29.6
Third-year student	10	18.5
Fourth-year student	9	16.4

Medical campus	n	%
OKC	39	73.6
Tulsa	14	26.4

Faculty results (N = 60)
Educator role	n	%	Clerkship director status	n	%
Preclinical	11	18.3	Director	27	45
Clinical	49	81.7	Not a director	33	55

Educator department	n	%	Course or clerkship type (N = 27)	n	%
Pediatrics	19	31.7	Medical student preclinical courses	8	29.6
Internal medicine	7	11.7	Medical student clinical courses	7	25.9
OB/GYN	5	8.3	Residency courses	7	25.9
Family medicine	4	6.7	Not listed	4	14.8
Psychiatry	4	6.7	Physician associate	1	3.7
Cell biology	2	3.3
Emergency medicine	2	3.3
None listed	2	3.3
Office of the dean	2	3.3
Orthopedics	2	3.3
Ear, nose, & throat	1	1.7
Medical informatics	1	1.7
Physician associate program	1	1.7
Radiology	1	1.7

OKC, Oklahoma City.

Among faculty respondents, 81.7%, (n = 49) taught one or more clinical courses, while 18.3% (n = 11) taught one or more preclinical courses. Educator departments included pediatrics; internal medicine; OB/GYN; surgery; family medicine; psychiatry; cell biology; emergency medicine; office of the dean; orthopedics; otorhinolaryngology; medical informatics; physician associate program; and radiology. Of the faculty respondents, 45% (n = 27) were clerkship directors, with 29.6% (n = 8) overseeing preclinical courses, 25.9% overseeing clinical courses for medical students, 3.7% (n = 1) overseeing physician associate courses, and 25.9% directing resident education. A total of 4 course directors did not indicate which courses they managed.

Quantitative Results

Students and faculty provided similar rates of estimated lifetime trauma prevalence for patients (65.7% and 63.1%), however, students reported higher estimated trauma prevalence for practitioners than faculty (63.6% vs 55.7%).

Familiarity with ACEs and TIC and perceived relevance to curriculum and clinical practice are described in Table 2. The faculty had a broader distribution of answers on familiarity with the 2 concepts than the students, with a greater proportion of faculty either not familiar or extremely familiar. Although students were less likely to have no familiarity with both concepts, more faculty had extreme familiarity with both concepts. Of students, approximately 11.2% and 27.8% were either not familiar or slightly familiar (1 or 2 on the Likert scale) with ACEs and TIC, respectively (see Table 2). However, 74.1% of students reported that TIC is very or extremely relevant to current curriculum, and 81.4% responded that TIC is very or extremely relevant to their future clinical practice (Table 2). Of the faculty, 60% indicated TIC was either very or extremely relevant to the information in their course, and 69.4% said TIC was very or extremely relevant to the clinical setting (Table 2).

Table 2:

Familiarity and relevance with adverse childhood exerperiences and trauma-informed care

Question and category of respondent	1 Not familiar	2 Slightly familiar	3 Somewhat familiar	4 Very familiar	5 Extremely familiar
How familiar are you with ACEs? a
Faculty	5 (9.8%)	9 (17.6%)	8 (15.7%)	16 (31.4%)	13 (25.5%)
Students	1 (1.9%)	5 (9.3%)	16 (29.6%)	28 (51.9%)	4 (7.4%)
How familiar are you with TIC?
Faculty	9 (17.6%)	4 (7.8%)	18 (35.3%)	12 (23.5%)	8 (15.7%)
Students	4 (7.4%)	11 (20.4%)	22 (40.1%)	15 (27.8%)	2 (3.7%)
How familiar are you with a trauma-informed approach to the physical examination?
Students (only)	12 (22.2%)	16 (29.6%)	14 (25.9%)	12 (22.2%)	0 (0%)

Question and category of respondent	1 Unsure	2 Not relevant	3 Somewhat relevant	4 Very relevant	5 Extremely relevant
To what extent do you think TIC may be relevant to the information presented in your course/clerkship?
Faculty (only)	3 (6.0%)	8 (16.0%)	9 (18.0%)	15 (30.0%)	15 (30.0%)
To what extent do you think TIC may be relevant to the clinical integration of information presented in your course/clerkship?
Faculty (only)	3 (6.1%)	5 (10.2%)	7 (14.3%)	16 (32.7%)	18 (36.7%)

Question and category of respondent	1 Not relevant	2 Slightly relevant	3 Somewhat relevant	4 Very relevant	5 Extremely relevant
How relevant is TIC to the current curriculum?
Students (only)	1 (1.9%)	2 (3.7%)	11 (20.4%)	27 (50.0%)	13 (24.1%)
How relevant is TIC to future clinical practice?
Students (only)	1 (1.9%)	3 (5.6%)	6 (11.1%)	22 (40.7%)	22 (40.7%)

Question and category of respondent	1 Not Comfortable	2 Slightly comfortable	3 Somewhat comfortable	4 Very comfortable	5 Extremely comfortable
How comfortable do you feel screening for a history of trauma?
Students (only)	3 (5.6%)	14 (25.9%)	22 (40.7%)	13 (24.1%)	2 (3.7%)
How comfortable do you feel responding to a patient disclosure of trauma?
Students (only)	5 (9.3%)	16 (29.6%)	18 (33.3%)	13 (24.1%)	2 (3.7%)

Question and category of respondent	1 Not confident	2 Slightly confident	3 Somewhat confident	4 Very confident	5 Extremely confident
How confident are you performing a trauma-informed physical examination?
Students (only)	18 (33.3%)	16 (29.6%)	13 (24.1%)	7 (13.0%)	0 (0%)

Question and category of respondent	1 Extremely dissatisfied	2 Somewhat dissatisfied	3 Neither satisfied nor dissatisfied	4 Somewhat satisfied	5 Extremely satisfied
How satisfied are you with the COM’s teaching on the impact of trauma on health and health care?
Students (only)	1 (2.3%)	16 (36.4%)	18 (40.9%)	7 (15.9%)	2 (4.5%)

^aIndicates P value of ≤ .05 when comparing students vs faculty responses via independent groups t test.

ACE, adverse childhood experience; COM, College of Medicine; TIC, trauma-informed care.

Students were asked to reflect on their experiences with TIC in the clinical setting. Among respondents, 38.9% had a clinical experience where TIC was involved, and 49% had an experience in which TIC would have been beneficial but was not provided. Furthermore, when course directors were asked if they address the impact of trauma on health in their course, 16 (57.1%) responded yes and 12 (42.9%) responded no. However, when asked if TIC was addressed in their course, only 10 (37.0%) of course directors responded yes.

The percentage of students who reported feeling very or extremely comfortable (4–5 on the Likert scale) screening for a history of trauma was 27.8%. Using the same scale, 27.1% felt very or extremely comfortable responding to a patient disclosure of trauma, and only 13.0% felt very or extremely confident in performing a trauma-informed physical examination. Furthermore, 51.8% of students responded that they were either not familiar or slightly familiar with the trauma-informed approach to a physical examination.

Approximately 20% of students reported satisfaction with the COM’s teaching of the impact of trauma on health and health care (Table 2), and 20.7% felt that TIC has been effectively addressed in curriculum.

Qualitative Results

Integration of TIC and ACEs in Courses and Clinical Experiences

Students reported that TIC had been taught in a limited number of didactic and clinical courses in their formal medical curriculum. These courses included clinical medicine (an introduction to clinical care); patients, physicians, and society (an introduction to socioeconomic and ethical factors that affect patient care); OB/GYN (clinical rotation); and lifestyle medicine (a Tulsa-specific course focusing on lifestyle impacts on health). Teaching modalities primarily consisted of small group sessions, didactic lectures, and workshops (Table 3). Beyond the formal curriculum, students also reported education on TIC through external seminars or workshops, student interest group meetings, simulations or work experience, and nonmandatory supplementary lectures given by the medical school.

Table 3:

Courses and modalities used to teach the impact of trauma on health or trauma-informed care in the current medical curriculum

Courses/clerkships
Student responses (n = 32)	Number of responses	Course director responses (n= 15)	Number of responses
Clinical medicine	10	PA program courses	2
Patients, physicians, and society	6	Human structure	2
OB/GYN	2	Psychiatry	2
Psychiatry	3	Internal medicine	2
Lifestyle medicine	2	Orthopedics	2
Lack of exposure	6	Pediatrics	3
Other sources	1	Patients, physicians, and society	1
		Trauma care	1

Teaching modalities
Student responses	Number of responses	Course director responses	Number of responses
Didactic lectures	3	Didactics	11
Small group discussions	7	Small group discussions	7
Workshops	3	Clinical experience/ward teaching	6
		Simulations	2

PA, physician associate.

Student-Reported Examples of TIC in Clinical Settings

Students reported a range of clinical experiences in which TIC was either observed or practiced. These experiences occurred during formal clinical rotations and prior work in the medical field. Specialties where TIC was more commonly observed by the students included emergency medicine and psychiatry, where students perceived these patient populations as often having complex trauma histories. Students identified specific patient groups, such as LGBTQ+ individuals and those who had experienced assault, as having particularly high needs for TIC.

Examples of trauma-informed practices included:

• Practitioners used a “talk before touch” technique to explain each component of the physical examination before proceeding.

• There was an even tone of voice and expressions of compassion when discussing trauma-related issues.

• There was the creation of a safe space for patients to grieve during trauma disclosures.

• There was the emphasis of autonomy and consent, along with practicing trauma-informed physical examinations.

• Students noted that such care was typically patient-centered, with clinicians showing empathy and understanding (Table 4).

Table 4:

Student reflections of clinical experiences in relating to trauma-informed care

(Students) Please give examples of clinical experiences where TIC was involved
Theme	Theme description	Number of responses
Specific populations and/or settings	Refers to the use of TIC in various settings such as clinical medicine evaluations and child and adolescent psychiatry rotations. This also includes references to specific patient populations, such as those identifying as 2SLGBTQ+ and/or those with a history of sexual assault, highlighting the need for specialized approaches to TIC for these groups.	11
Patient-centered approaches	Responses include clinical settings where TIC skills were used. Students mention skills such as ensuring patient autonomy and consent were acknowledged and explaining components of the physical examination prior to touching the patient. They also note the practitioner’s role in recognizing trauma and promoting patient comfort.	5
Empathy and understanding	This theme involves having even-toned sympathy when patients disclose traumatic events, responding with compassion and understanding when a patient discloses a history of trauma, and allowing parents of patients to vent and grieve.	3
Prior job experiences	Responses include experiences before medical school in previous jobs, suggesting a theme of ongoing learning and development in TIC outside of medical school.	2

(Students) Please describe clinical experiences in which TIC may have been beneficial but was not provided.
Theme	Theme description	Number of responses
Need for education, specific situations	Identification of specific need for integration of TIC in medical education or specific settings where TIC could have been beneficial.	5
Lack of time and knowledge	Health care practitioners often lack the time or knowledge of TIC principles to appropriately provide TIC.	5
Previous jobs	Reflections on previous jobs where TIC was not used or taught, indicating a broader need for TIC in a variety of medical settings.	4
Lack of sensitivity	Includes instances where health care practitioners lacked sensitivity toward patients’ traumatic experiences, including cases of domestic violence, childhood abuse, and discomfort around medical procedures.	2
Inappropriate behavior	Describes situations where health care practitioners behaved inconsistently with TIC. Examples include performing sensitive examinations without prior explanation and asking permission for medical students to be in the room while the patient is already prepped for a pelvic examination.	2

Note: Students were prompted to reflect on their experiences in which TIC was provided and where TIC was not provided but may have been beneficial. Response themes were analyzed and quantified by number of responses that included a particular theme.

2SLGBTQ+, Two Spirit, Lesbian, Gay, Bisexual, Trans, Queer, +; TIC, trauma-informed care.

Clinical Encounters Without TIC Student Reflections on Missed Opportunities

Several students described experiences where TIC was noticeably absent but could have substantially benefited the patient. A recurring theme was the lack of practitioner awareness or education on trauma-informed practices. Some practitioners were described as insensitive, using language or behaviors that contradicted TIC principles.

For example, patients were asked if they were comfortable with medical students observing a pelvic examination only after they had been prepped and positioned, which disregarded the importance of prior consent. Students also observed that practitioners were often constrained by time and lacked the knowledge necessary to provide TIC (Table 4).

Students also noted power dynamics that made it difficult to address these concerns. One student reflected (as described in Table 5),

Table 5:

Notable student responses to various survey questions. and corresponding prompts

Prompt	Student response
What, if anything, is missing from the COM’s curriculum to address trauma and TIC?	It should be integrated throughout the curriculum rather than simply delegating it to a token lecture or opt-in workshop on the side.
	Not only do they need to have at least one session about it (TIC), but also . . . as someone that would benefit from TIC, I didn't feel comfortable attending the one session they offered on it with a bunch of my classmates and friends but I do want to learn, so there should be a self-paced at home or individual one for those of us that would prefer something like that.
Please describe clinical experiences in which TIC may have been beneficial but was not provided.	Any time patients disclose history of domestic violence on their screening form, I've seen residents not have time to screen further or not know what do about it.
	When large patient load and little time forced a resident to close out conversations regarding trauma prematurely.
	Working with various physicians across different specialties, I have been party to instances where TIC would have been of benefit to the patient, but the physician was not trained/did not understand trauma-informed care, so it went unsaid. I did not feel comfortable, as a student, interjecting myself into the situation at that time.
Are there any other comments/suggestions about TIC to share?	It is important for us to learn about TIC to be able to deliver the most effective care to our patients. Any additional training or working it in the existing curriculum would be good.
	I think we sometimes forget that some of us students have experienced the trauma we discuss in the curriculum. Specifically ACEs conversations. Some of us have more than 4 ACEs and sometimes these concepts are discussed in a way that only focuses on the patients we will be seeing as if no one in the room might have experienced these things as well. It’s never malicious or necessarily a horrible thing, but I think it’s important to note that even medical professionals and future medical professionals come from significantly traumatic backgrounds as well.

Note: Students provided free responses to various survey questions. Notable example responses and corresponding prompts are in this table.

ACE, adverse childhood experience; COM, College of Medicine; TIC, trauma-informed care.

“Working with various physicians across different specialties, I have been party to instances where TIC would have been of benefit to the patient, but the physician was not trained/did not understand trauma-informed care, so it went unsaid. I did not feel comfortable, as a student, interjecting myself into the situation at that time.” Additional responses are also shown in Table 5.

Curricular gaps in addressing trauma and TIC: Student and faculty perspectives

Students suggested several ways to strengthen the curriculum. These included offering more formal training and structured opportunities to practice TIC skills, introducing TIC concepts earlier in the medical education timeline, providing self-paced online modules to supplement in-person instruction, and increasing access to relevant workshops (Table 6).

Table 6:

Students’ perceived gaps in trauma-informed care curriculum

What, if anything, is missing from the COM’s curriculum to address trauma and TIC?
STUDENTS			FACULTY
Theme	Theme description	n	Theme	Theme description	n
Formal education, training, and practice	Ensuring formal education and practice on TIC: embedding TIC in formal curriculum, more simulation and practice, incorporation into clerkships, specific course, etc.	7	Incorporation of specific TIC content	Incorporation of specific TIC content (ie, specific treatment modalities, differential diagnosis, impact of trauma on physiopathology, etc)	4
Workshops	Implementing clinical medicine workshops to cover the basics of TIC.	4	Faculty development & expertise	Ensuring that faculty who are involved in medical student education are adequately educated about TIC and ensuring that all faculty are included.	4
Earlier exposure to TIC	Introducing TIC early in the curriculum, potentially as a part of clinical medicine 1, and before third-year rotations.	3	Curriculum integration & teaching modalities	Incorporating TIC throughout courses rather than treating it as a stand-alone topic. Specific modalities to deliver TIC content (simulation, practice).	3
Self-paced learning	Provided self-paced or individual learning options for those who may not feel comfortable attending group sessions.	1	Workplace culture	Creating a workplace culture where secondary traumatic stress and practitioners’ own emotional reactions to the work can be shared without fear of negative consequences.	1

Students and faculty were asked what, if anything, was missing from the COM’s current teaching on trauma and TIC. Response themes were analyzed and quantified by number of responses that included a particular theme.

COM, College of Medicine; TIC, trauma-informed care.

Faculty members echoed these concerns and proposed additional strategies for improvement. They emphasized the need for more structured TIC content, particularly material addressing treatment modalities and differential diagnoses. Many faculty members identified the importance of faculty development initiatives to build educators’ comfort and competence with TIC principles. They also recommended better curriculum integration and more intentional teaching methods to ensure consistency across courses. Furthermore, several faculty members underscored the importance of fostering a workplace culture that recognizes and supports practitioners in managing the emotional toll of trauma-related care.

One faculty member candidly acknowledged their own limitations, stating, “Faculty who are involved in medical student education, such as myself, are not educated enough about this concept to teach it.” Another added, “I think this is a crucial topic for medical students and trainees, but one that many faculty do not feel equipped to teach in a formal way. I support more resources, research, and education in this area.” In addition to educational gaps, faculty highlighted the need for safe environments where secondary traumatic stress and the emotional impacts of clinical work could be openly discussed without fear of negative consequences.

Improving TIC within the curriculum

Both students and faculty were asked to identify gaps in TIC education and suggest ways to strengthen its integration into the medical curriculum. Student responses highlighted the need for more formal instruction, more hands-on training opportunities, and earlier exposure to TIC principles, workshops, and self-paced learning modules (Table 6).

Faculty echoed these themes while also emphasizing the need to incorporate specific TIC content, such as treatment modalities and differential diagnoses, into existing courses. They also pointed to the importance of faculty development to build the knowledge and confidence needed to teach TIC effectively. Additional recommendations included integrating TIC more deliberately across the curriculum, selecting appropriate teaching modalities, and cultivating a workplace culture that supports discussions about the emotional demands of trauma-related care.

One faculty member noted a key barrier to implementation: “It takes intentional efforts to create a workplace culture where secondary traumatic stress (STS) and providers’ own emotional reactions to the work can be shared without fear of negative consequences. [It’s a] good place to explore if people feel comfortable talking about the impacts on self.” Also, faculty members emphasized the need for additional institutional support, stating that more resources and education on TIC would be welcomed by faculty who feel they are unequipped to formally teach on the topic.

Discussion

Importance of TIC in medical education

The authors’ survey of medical students and faculty found that both groups perceived TIC as important to the medical school curriculum and integral to compassionate, patient-centered clinical care. However, the findings indicated that TIC is incorporated inconsistently across preclinical courses and clinical settings, lacking a cohesive and structured approach. Furthermore, students reported varied exposure to TIC outside of the formal medical curriculum, contributing to disparities in their knowledge and preparedness regarding TIC.

Student Discomfort with TIC Skills

Student responses indicated discomfort with key TIC skills, including screening for a history of trauma, responding to a trauma disclosure, and performing a trauma-informed physical examination. This discomfort likely reflects the inconsistent teaching of TIC principles and indicates a need for greater integration of TIC into the curriculum. ²⁰

Gaps in Knowledge Between ACEs and TIC

Both students and faculty perceive trauma as a prevalent issue among patients, but it is still at lower levels than the data show. ^1,2 Faculty and students are more familiar with the term “ACEs” compared to the term “TIC,” suggesting a gap between knowledge and practice. Although knowledge and understanding of ACEs and their effects involves primarily conceptual understanding, TIC involves complex skills training. Faculty may lack the skills and expertise to incorporate TIC into their teaching, as they likely did not receive this training during their own medical training. Increasing faculty education on TIC could provide the necessary tools to practice and teach these principles, facilitating its integration into the medical school curriculum. ²¹

Barriers to TIC Integration

Additional barriers to the integration of TIC include faculty skepticism about its relevance and a lack of a supportive workplace environment. Addressing these barriers would require increasing awareness of the impact of trauma on disease pathophysiology, the positive influence of trauma-informed approaches on patient health outcomes, and the student desire for greater TIC incorporation into curriculum. The authors’ data revealed an interesting 20 percentage point difference between course directors’ responses that they addressed the impact of trauma in their courses (57%), compared with only 37% responding that TIC was addressed in their courses. This highlights the relative ease of including teaching about how trauma can impact health as compared to the more complex practice of teaching TIC skills to students. Teaching TIC as a single-time session without integration, which is common in current curricula, risks relegation to nonessential or elective status. ^17,21,22 Other future research could include obtaining patient perspectives, evaluating experiential learning through simulation, and assessing the impact of having a faculty thread director focused on TIC in the overall curriculum.

Campus Differences in TIC Exposure

Differences between the campuses of OKC and Tulsa were evident in student perspectives. Tulsa students reported having more exposure to TIC in clinical settings, believed TIC was more relevant to clinical practice, and were more satisfied with TIC in the curriculum than OKC students. The University of Oklahoma School of Community Medicine is an integrated track within the University of Oklahoma COM that provides students with the knowledge and skills necessary to serve as well-rounded specialty or primary care physicians, while learning a special skill set to improve the health of entire communities.

It is possible that the differences may be attributable to the focus on community medicine and social determinants of health present in the Tulsa curriculum, including the additional TIC training incorporated into Tulsa-only experiences, or to differences in faculty interests and teaching foci. These campus differences highlight the need for awareness of existing TIC teaching, limiting the option of a “single size fits all” approach to introducing and enhancing TIC across medical schools.

Study Limitations and Directions for Future Research

This study offered valuable insights into the integration and perception of TIC within UME, incorporating perspectives from both students and faculty. However, its findings were limited by a small sample size from a single medical school and a low response rate, which may have affected generalizability. Despite the low response, the authors feel that the information gathered is still quite helpful to understanding the emerging field of teaching TIC to medical students. It is certainly possible that the responders were skewed toward both students and faculty who already had an interest in this topic. If that is true, the quantitative data on level of knowledge, experiences, confidence, and importance of TIC are higher than average. If more students and faculty who were unfamiliar or uninterested in this topic were to have responded, the authors might have expected lower levels in all of these areas (knowledge, experience, confidence, and importance), which would only confirm the need for more attention to teaching TIC in UME. Also, the qualitative responses added richness and potential guidance for the future to the quite limited data on UME TIC education.

Contemporary challenges to incorporating TIC include pressure from compression of preclinical curriculum, lack of evidence-based models, and lack of availability of skilled faculty in all disciplines. Teaching TIC as a one-time session without integration, which is common in current curricula, risks relegation to nonessential or elective status. Additional future outcomes research could include obtaining patient perspectives, evaluating experiential learning through simulation, and assessing the impact of having a faculty thread director focused on TIC in the overall curriculum.

Recommendations for Longitudinal Integration

The authors propose an approach to teaching TIC that may be distinct from common approaches to teaching clinical concepts. Although a single lecture on a specific disease state may be sufficient and later be reinforced during clinical rotations, TIC necessitates longitudinal and coordinated efforts. Furthermore, its principles of safety, transparency, and collaboration must permeate each patient interaction and the broader medical institutional culture.

Achieving this requires the engagement of all medical education stakeholders, including leadership, faculty, residents, fellows, clinic and hospital staff, lecturers, and students. ²³ To ensure continuity and reinforcement of TIC concepts, the authors recommend creating a team responsible for overseeing the integration of TIC throughout all phases of the undergraduate medical curriculum. This team should actively seek student feedback to ascertain their experience of workplace culture and guide meaningful change.

Evidence-based models for teaching are lacking, although interest is growing and new models are emerging across medical schools. ^17,21,22 Integrating TIC across medical education is a complex challenge, but incorporating its principles across all domains would open a space of healing and recovery for both health care professionals and patients.

Implications for Practice and Policy

The findings of this study point to several important implications for both clinical practice and institutional policy. To meaningfully integrate TIC into medical education, institutions must move beyond optional lectures or isolated simulations and embed TIC principles throughout the curriculum and clinical training environments. Practically, this means creating structured opportunities for students to learn the foundational science underlying TIC and practice TIC skills, such as responding to trauma disclosures and conducting trauma-informed physical examinations, under guided supervision. At the institutional level, medical schools should develop educational frameworks that prioritize TIC as a core competency, supported by faculty development programs, curricular benchmarks, and accountability measures. At the policy level, accreditation bodies, testing entities, and educational systems leadership can play a pivotal role by promoting TIC-related learning using specific frameworks and guidelines, such as SAMHSA, ⁷ UME TIC competencies, ¹⁴ and/or TIC entrustable professional activities, ¹⁷ in standards for medical education. Furthermore, institutional policies that promote emotionally safe learning and clinical environments are necessary to model trauma-informed principles not only in patient care, but also in the treatment of students and health care staff. These measures can foster a more compassionate health care culture, improve patient outcomes, and contribute to the well-being and professional identity formation of future physicians.

Supplementary Material

online supplementary file 1:

online supplementary file 2: