An Examination of Trauma-Informed Medical Education in the Emergency Medicine Clerkship: Opportunities for Learner-Centered Curricular Development.

Purpose: During the Emergency Medicine (EM) clerkship, medical students are immersed in high-stress, traumatic incidents with their patients and clinical teams. Trauma-informed medical education (TIME) applies trauma-informed care principles to help students manage this trauma. We sought to collect, describe, and analyze medical students’ EM clerkship experiences from the lens of the TIME framework to guide curriculum development. We applied the critical incident technique (CIT) to (1) qualitatively capture students’ critical incidents and (2) identify gaps in trauma-informed approaches to education in the clinical learning environment. Method: We employed a constructivist grounded theory approach to explore experiences of third-year medical students who had immediately completed the EM clerkship at a single, urban, academic medical center. We used the CIT to elicit narratives to better understand the core components of the TIME framework as they appear in the EM clerkship. In August 2022, 12 third-year medical students were interviewed and asked to describe a traumatic incident they observed/experienced and the impact the clerkship had on their ability to manage the situation. Interviews were virtual, recorded, and transcribed. Participant size was informed by data saturation, information power, as well as analytical and data sufficiency. We re-storied narratives to build a cohesive, chronological story in the participants’ own words. Using the framework method, transcripts were analyzed: (1) inductively by developing iterative assertions, patterns, and organizing themes across participants’ incidents relevant to TIME and (2) deductively by categorizing findings into 1 of the 6 principles of the TIME framework. Results: Consistent with current literature, the EM clerkship exposes students to trauma as they navigate learning and patient care. Students were not prepared to navigate the guilt associated with not being able “to do enough for [their] patients,” as well as the hidden curriculum for “performing well” in the clerkship while balancing what is morally acceptable for the patients they cared for. Students had to reconcile the lack of closure of significant events in the clinical environment amidst the isolation and breakdown in communication they felt from the rest of the care team. Students struggled with both observing and experiencing discrimination in the workplace, and managing the internalized pressure to speak up against power dynamics on behalf of their patients. Our analysis highlights the need for frequent and consistent debriefs that emphasize closure, correction of disparities between morally and academically acceptable actions, and educational structures that foster educator trust in students’ skills and responsibilities. Discussion: Data from students’ critical incidents provides rich insights that clarify our understanding of what student experiences look like when working in high-stress clinical learning environments. Our data supports TIME as an appropriate framework to guide trauma-informed and learner-centered educational programming. Critical incidents of medical students’ clerkship experiences offer opportunities for curricular development in the EM clerkship that can better support students as they work through the trauma of their formal clinical training, as well as addressing workplace-related factors that have the potential to impinge on student well-being. Significance: There is a need to design and prepare for student clinical experiences in a formal curriculum that link to TIME principles. These principles include peer support; student empowerment, voice, and choice; collaboration and mutuality; trustworthiness and transparency; learner safety; and cultural, historical, and gender considerations. Our findings can guide educators to scaffold trauma-informed clinical experiences across various high-stress clinical learning environments for their respective students.