The Ethics of Trigger Warnings

December 09, 2022

Information

December 7, 2022

Douglas Shenson, MD, MPH, MS, MA

Tia Powell, MD

Beverly Sheares, MD, MS

ID9263

To CiteDCA Citation Guide

00:00OK, everybody set.
00:05OK, to you. You got to sneeze.
00:07Now is your chance. Too late.
00:09I'm going to start to start
00:10to record. Here we go.
00:27Well, good evening and thanks for coming.
00:30We haven't. We have a special night tonight,
00:32which we'll get to in a minute.
00:33But as we always do, because it's a hybrid
00:36program between in person and zoom,
00:37we're going to give a couple more
00:39minutes as the zoom room fills up.
00:40We have some wonderful panelists tonight
00:42to talk about an interesting issue,
00:44and I'm going to turn the
00:45the podium over in a minute,
00:47but I'm going to say just please
00:48hang on for a couple of minutes.
00:50To those on zoom world and everyone else,
00:52welcome to the program for Biomedical
00:54Ethics Evening Ethics Seminar series.
00:56My name is Mark. Mercurial,
00:58I'm the director of the program tonight.
01:00Doctor Sarah Hall,
01:00who is the associate director of our program
01:02and a member of our cardiology faculty,
01:04will be moderating our
01:06discussion on trigger warnings.
01:07It was Doctor Doug Shenson who
01:09contacted us sometime back with
01:11what I think was an excellent idea
01:13that we have this conversation.
01:14So we're really looking forward to it.
01:16I'm going to turn the podium over now
01:18to Sarah and suggest you wait until
01:20like 503 or five O 4 as they come
01:22filling in and then we'll rock'n'roll.
01:24So anyway,
01:25thanks so much for coming you guys,
01:26and look forward to a good conversation.
01:28Doctor hall.
01:36So thank you, Mark.
01:38I I will indeed wait until about
01:41503504 for us to get started.
01:43So everyone else, settle in.
01:45If you're at home, now's the time
01:47to pull a few shots of espresso,
01:49maybe, maybe some decaf depending
01:51on the what your cutoff time is.
01:53But we'll be starting shortly.
02:02Yes, everything. There's no
02:04hard answer but like the whole
02:07so there's no
02:09questions must, must start right.
02:11You know we give everyone.
02:14The hard stuff, and I'll be clear, yeah.
03:24Alright, in the interest of time,
03:26because we really have a wonderfully
03:28packed night with a lot of wonderful
03:30speakers who have joined us.
03:32I think we should get started.
03:33Can everyone hear me?
03:34OK. All right, great.
03:37And so I will what were the way
03:40this is going to work for those
03:41of you've heard the spiel before
03:43if you've come to our events,
03:44but if not just to be so that we have
03:46a sense of how tonight's going to work,
03:48I'm going to introduce our panelists.
03:51We have two in person, of course,
03:52one on zoom and then we're going
03:54to turn it over to a moderated Q&amp;A.
03:57We have some special guest medical
03:59students who have come to also share,
04:02who have prepared some remarks
04:03to share their experiences and
04:05their insights on this issue.
04:07And so we're really pleased to
04:08have them as well and and we do
04:11have a hard stop at 6:30 PM.
04:15So I just because we want to make
04:17sure that we respect everybody's time.
04:19So I will try to call on as many
04:21people as possible both in person
04:24and through the zoom.
04:25So we will be looking at monitoring
04:27the zoom questions as well.
04:28So please feel free to submit your
04:30questions through the zoom as the
04:32panel progresses and otherwise for
04:34in person save your questions and we.
04:36Are looking forward to having
04:37a really robust discussion.
04:39So thank you all for coming.
04:41So we're going to get started.
04:42Our first speaker is the one who as
04:47Mark said had approached us with
04:49this really great idea to talk about
04:51some of the ethical considerations
04:53involved in trigger warnings.
04:55Dr Doug Shenson,
04:56who is an associate clinical professor
04:58of epidemiology and public health
05:00at the School of Public Health and
05:02Associate Professor Adjunct section
05:04of General Internal Medicine at
05:06the School of Medicine.
05:07He is also the director of our preclinical
05:11course populations and methods,
05:12the application of epidemiology and
05:15Biostatistics to public health,
05:16and he's the deputy leader of the
05:19School of Medicine HealthEquity
05:20thread at Yale.
05:22Earlier in his career,
05:23he worked in the division of
05:25Bioethics within the Department of
05:26Epidemiology and Social Medicine at
05:28Albert Einstein College of Medicine.
05:30Doctor Shenson is a co-founder
05:31of Doctors of the World USA,
05:33which is now known as Healthright
05:36International,
05:36and he's the founding director
05:37of the Human Rights Clinic at
05:39Montefiore Medical Center,
05:40the first clinic in New York City
05:42to attend exclusively to the needs
05:44of survivors of torture applying
05:46for political asylum.
05:47He is on the board of directors of
05:49the International Association for
05:50Indigenous Aging, or I squared,
05:52which is committed to the provision
05:54of quality services for indigenous elders.
05:57He has worked on projects with
05:58the CDC for 20 years,
05:59focusing on population wide
06:01delivery of preventive services.
06:03Doctor Shenson holds degrees
06:04from University of Pennsylvania,
06:06Oxford, Tulane School of Medicine,
06:08Tulane School of Public Health
06:10and Tropical Medicine,
06:11and Harvard School of Public Health.
06:13Take it away, Doug.
06:21Thank you, Sarah,
06:22and thank you all for coming.
06:23I've been looking forward to this
06:25discussion for several months.
06:28Nora Ephron, who was an accomplished
06:31journalist and screenplay writer,
06:32used to say that everything is copy,
06:35and what that meant to her
06:37was that every conversation,
06:38every family gathering,
06:39every encounter was a legitimate source,
06:42material and creativity for.
06:44The writer I think there must be some
06:48equivalent principle in bioethics
06:49where every difficulty or every
06:52hesitation encountered in the work
06:54that we do is legitimate grist for
06:57reflection and bioethical analysis.
06:59And that's where this meeting
07:02and discussion begins.
07:04I encountered the same issue twice recently,
07:07and twice in quite short order.
07:11To backtrack a little,
07:12rob Holmer,
07:13who directs the pathology curriculum,
07:15asked me several years ago if I would
07:17be willing to incorporate forensic
07:19pathology and training in death
07:22certification in my public health
07:24course populations and methods.
07:26This struck me as an interesting idea,
07:29since we could connect a clinical matter,
07:32that is to say filling in
07:34a death certificate,
07:34which involves identifying a chain
07:38of pathophysiological causation,
07:40with the emergence.
07:41Of public health mortality data.
07:44Furthermore,
07:44forensic pathology is intimately
07:46connected with the conditions of living,
07:48whether it be car wrecks or violent crime,
07:51or an unexpected death for any reason.
07:54Rob mentioned to me that he had previously
07:56invited the Connecticut medical
07:58examiner to lecture on this topic,
08:00Doctor Jim Gill,
08:01and he would make an introduction for me.
08:04Since it's difficult to turn on cable
08:07TV without encountering a coroner.
08:09I thought this.
08:10I thought that first year students
08:12would find this presentation of
08:14real life events very interesting.
08:15I mean, what could go wrong?
08:19So last fall, Jim Gill came to the lecture.
08:22He is a very open,
08:23professional and accessible lecturer.
08:24He told students that there would
08:27be some slides in the talk that
08:29might make them uncomfortable,
08:31but that was the nature of the topic.
08:34No doubt. This was a lecture.
08:35He had given many forms and some of the
08:38slides were indeed very discomforting.
08:40There were images of bullet wounds
08:42and head trauma and so forth.
08:44But there was nothing in the lecture that
08:46I think could not be found in a pathology.
08:49Textbook or even say in a 60
08:52minute TV report or expose.
08:55A second experience occurred
08:57after Doctor Shears and I,
08:59under the banner of HealthEquity thread,
09:01organized the talk for the 2nd year
09:03students during their clinical clerkships.
09:06This was part of the regular
09:09so-called preceded series which the
09:11class shares between rotations.
09:14So we organized the session to
09:16address in various ways the
09:19HealthEquity consequences of the
09:21states monopoly on violence.
09:24In 1993, I,
09:25as Sarah mentioned,
09:26I had launched a clinic in the New
09:29York City bars in the Bronx to address
09:31the documentation and medical needs
09:33of persons applying for political
09:35asylum who claim that they had been
09:38tortured in their country of origin.
09:40And even though she would
09:41have no reason to remember,
09:43some of the best practical clinical advice
09:46I got in 1993 was from Doctor Tia Powell.
09:49So I am particularly pleased
09:50that T is with us again tonight.
09:53So in this lecture in the precede,
09:56after indicating that some of
09:58the material would be disturbing,
10:00I discussed my experience working
10:02at the Human Rights Clinic and
10:04I introduced slides which had
10:06different types of scarring and
10:08burns and musculoskeletal injuries,
10:10and discussed the psychological
10:12impact of trauma on my patients.
10:15I also discussed the advocacy work
10:17that we did writing medical affidavits
10:19and defending them under cross
10:22examination and Immigration court.
10:23All the slides were presented as they would
10:25have been in any professional setting.
10:27Now to get to the number that
10:30on both occasions we received
10:32among positive feedback,
10:34several stinging student reviews,
10:36that there were insufficient or no
10:39trigger warnings for the sessions.
10:42The students seemed appalled.
10:44The ones who wrote this one student
10:47noted in direct conversation with me
10:49that Doctor Gill had discussed his
10:51offices work on a recent plane crash.
10:54Outside Hartford,
10:55which you may remember,
10:57and that she had known someone
11:00affected by the crash and so
11:02found the talk very upsetting.
11:04So these this is difficult
11:06material and there was difficult
11:08material in the presentations,
11:10but I have to say that I found the
11:13reactions that they perplexed me.
11:16In both circumstances,
11:17the lecture had given a caution and I'm
11:21completely supportive and think that it's
11:24important to give this type type of warning.
11:27But I think it really goes without
11:30saying that generally in medicine there
11:32is no such thing as a trigger warning.
11:34We are trained to be to try to be
11:37ready no matter what comes into the
11:40clinic or into the emergency room.
11:43So.
11:44In thinking about how perplexed I was,
11:47I wonder it is this just a reflection of
11:49early days of professional development?
11:52Perhaps this was a different
11:54conception of what the medical
11:56student experience will be?
11:58Could this have been avoided if
12:00Doctor Gill's lecture had stayed
12:03under pathology rather than public
12:05health? And had we
12:07more generally, as medical educators,
12:10failed to prepare or frame the content
12:14of medical education adequately?
12:17And so with all these questions,
12:19I did what I'm trained to do.
12:21I thought about a differential
12:22diagnosis and I called in a consult,
12:25which is you guys?
12:28It seems to me that
12:29there are four interlocking components here.
12:32One what are reasonable expectations of
12:35students when encountering forms of trauma?
12:38Is there any kind of obligation for
12:41students to do the difficult emotional work
12:44of engaging with this kind of material?
12:47Secondly, what are our
12:50responsibilities as medical educators?
12:52How do we help build a professional
12:55identity that enables and empowers
12:58students to handle exposure to
13:01situations that either describe
13:03trauma or are themselves traumatizing?
13:06Are there medical students?
13:08Whose own personal histories of are
13:10there medicals who have histories
13:13of trauma in their own life,
13:14for whom
13:15it is ethically inappropriate
13:17to present them with such material?
13:19Thirdly, how do we assure that
13:23our students understand? That.
13:27How do we assure students that we know
13:32that certain professional encounters
13:34with persons or material can be truly
13:38and lastingly hurtful and harmful?
13:41These feelings are real and in a
13:43society riddled with injustice.
13:47Unfortunately, activating such
13:48emotions is all too easy and frequent.
13:52And lastly, how do we get past the
13:55metaphor of the trigger warning?
13:57It seems to me extremely limited.
14:00It would be as if if our mission were to
14:03decrease harm from vehicular accidents,
14:05all we could do was tighten the seat belt
14:08and set the crash bag to go off earlier.
14:12So lastly, let me just say a few words about
14:15why I think this discussion is important.
14:18When I was working at
14:19the Human Rights Clinic,
14:20the most important thing I did was
14:23listen to my patients history.
14:25And it is difficult to sit with a patient
14:29describing a traumatizing experience,
14:31but important when doing so,
14:33to engage, to be open,
14:35to be supportive,
14:36to be encouraging and to be
14:39right there with them.
14:41And when you do,
14:42you can feel them struggling
14:44with the questions that always
14:46accompany severe trauma.
14:47Will I ever be able to reconnect with others?
14:51Will I ever be able to get past this?
14:55So this solidarity is at
14:57the core of what we do,
14:59and it is the critical ingredient in healing.
15:02There is no such thing as someone
15:06disclosing an unspeakable experience.
15:08Without there being a listener,
15:10and that listener is us.
15:13So let me close by saying that the
15:15notion of trigger warnings to me is
15:18just the key that unlocks the door.
15:20What's needed is to get past it,
15:23to unpack the elements,
15:24and then after we've done that,
15:26perhaps we can put the pieces back
15:29together in a way that is constructive.
15:32Empowering and helps build the
15:35confidence and resilience that
15:37young doctors will need.
15:39Thank you.
15:49Thank you so
15:50much Doug for that great
15:51introduction to the topic and also
15:53for sharing your your insights.
15:55Now I have the pleasure of
15:57introducing our next speaker,
15:59Doctor Beverly Shears,
16:00who is an associate professor of
16:02Pediatrics in the pulmonary allergy,
16:04immunology and Sleep Medicine
16:05section at the School of Medicine.
16:08Doctor Shears serves as the director for
16:10the Pediatric Pulmonary Fellowship program,
16:12the medical director of the Aerodigestive
16:14program and the HealthEquity thread
16:16leader at Yale School of Medicine,
16:18Doctor Shears.
16:19Earned her undergraduate and
16:20medical degrees at the University
16:22of North Carolina at Chapel Hill.
16:24She completed her residency in
16:26Pediatrics at the Children's
16:27Hospital of New York Presbyterian,
16:29Columbia,
16:29where she served as chief resident
16:32in Pediatrics.
16:32Following residency training,
16:34she worked for three years as a
16:36pediatric emergency medicine physician
16:37at Harlem Hospital Center in New York City.
16:40She returned to Columbia to complete
16:42a postdoctoral fellowship in pediatric
16:44pulmonary medicine and subsequently
16:46joined the faculty at Columbia.
16:47Doctor Sheares earned a Masters degree
16:50in Biostatistics focused on patient
16:51oriented research at Columbia's
16:53Mailman School of Public Health.
16:55And she served as a pediatric pulmonary
16:57fellowship director for several years
16:59and mentored many medical students,
17:01residents and fellows.
17:02After a long career at Columbia,
17:05we were very lucky to have doctor Shears
17:07join our faculty at Yale in 2018,
17:10and she is the recipient of numerous
17:12teaching and mentorship awards.
17:14Thank you,
17:14doctor Shears.
17:26So the way I approach this
17:28topic of trigger warnings.
17:30I started to think about it
17:33from a pedagogical as well as
17:35a HealthEquity perspective.
17:37And in thinking about trigger warnings,
17:41I think the use and the need for trigger
17:45warnings speaks to a larger issue in
17:49medical education and in HealthEquity.
17:52Many people report being triggered by
17:55issues related to inappropriate use of race,
18:01stereotyping and bias around LGBTQIA,
18:04plus issues callous treatment of
18:08disabilities, death and dying,
18:10and many other topics.
18:13And I think it's really important in
18:16medical education where students are
18:18going to be confronted with a number
18:21of human conditions and situations
18:23that are disturbing, painful,
18:26that we grapple with these issues.
18:31The students will be confronted
18:33with disturbing images as Doug just
18:36talked about patient experiences.
18:40And.
18:41In the midst of being confronted
18:45with those issues,
18:46their own pain may surface.
18:50How they deal with their own pain
18:52and how we as medical educators
18:56deal with students is integral to
19:00their professional development.
19:03Hate man in her article why
19:05I use trigger warnings?
19:07Suggests that the use of trigger
19:10warnings does not actually keep students
19:13from engaging in difficult material.
19:17Rather,
19:18it helps them to prepare themselves
19:22for the material and better
19:24manage their own reactions.
19:26And and I think that is an important.
19:31That I think that's really
19:33an important concept.
19:34It gives students some more autonomy
19:37over their own learning when they know
19:41that something painful may be coming.
19:45However. There are some studies that show.
19:50That when trigger warnings are used.
19:54Contrary to those who are opposed to the
19:56use of trigger warnings that students
19:58actually don't run away from the material.
20:01They do forge ahead.
20:03But we as medical educators have
20:06to set the conditions such that
20:09they are able to move forward.
20:12Now, having said that.
20:16I think it is important
20:18as a medical educator.
20:20That when we are going to handle
20:23or tackle difficult situations,
20:25different difficult conversations,
20:27it is impossible for us to know
20:31everyone who's in the room or
20:33everyone who is on rounds, right?
20:36We can't. I can't know what you all
20:39have experienced if I don't know you.
20:41So that speaks to the need for relationship.
20:47Between faculty and students.
20:49Just as you're going to build relationships
20:52between students and their patients,
20:56in order to know you,
20:57I have to be in relationship with you.
21:00And that then both informs me as a
21:04medical educator in terms of how I
21:07teach you what I know, your triggers,
21:10I know some of the things.
21:13And that helps you when you're
21:14dealing with your patients.
21:15If you know them and you know their lived
21:18experiences, that is really helpful.
21:20Not only for your relationship,
21:23but for their healing. I think.
21:27Depending on the trigger,
21:29the level, the depth of the harm.
21:33I think it is important for us as
21:35medical educators to understand.
21:37That when a student is triggered.
21:41Learning stops.
21:45Right. People have when they are
21:47when our students are triggered.
21:49Their minds are right at the trigger,
21:51at the pain, and we go on teaching
21:54and we have left that student behind.
21:57Maybe it's for a minute,
21:58it could be for the rest of that lecture,
22:00or it could be for the rest of rounds.
22:03And since our goal is to reach
22:06and teach all of our students,
22:08I think it is important for us to
22:11keep that in mind as we move into
22:15discussing issues that address
22:17sensitive or controversial,
22:20or issues where the historical context
22:24of maltreatment of any sort is discussed.
22:29So. When I'm thinking about my
22:34role as a medical educator.
22:37And from a HealthEquity perspective?
22:40I think this this speaks to the need.
22:43To teach with care.
22:46With courage, authenticity,
22:49responsibility and empathy.
22:52And if we do that around all the topics?
22:56It'll reduce the need for a trigger warning.
22:59Because we will have taken into account.
23:04The myriad of ways that words,
23:07images and cause harm.
23:11So I'll come back to this in a in a bit.
23:14So as the students often say.
23:16So tell me what we can do right
23:18at the end of all of this,
23:20soon as we want to know what's the action.
23:22And what I would say is I went
23:26to the literature.
23:27And it turns out that in a number of studies,
23:31trigger warnings have probably
23:34minimal effect.
23:36In terms of being that helpful,
23:38they may not be that helpful at all.
23:42A study by Bullet Jones and McNally,
23:45psychologists out of Harvard,
23:48showed that for people who
23:51believe that words can harm.
23:53Trigger warnings actually
23:55increase their anxiety.
23:57And for people who don't
23:59think that words harm.
24:01It had no effect.
24:03There have been subsequent
24:05studies after this,
24:06many of which that show that they
24:09probably have trigger warnings
24:11have probably minimal effect.
24:13So if trigger warnings have minimal effect.
24:17But students are still triggered.
24:21What's the solution?
24:24That gets back to teaching and interacting
24:27with care and developing relationships.
24:30Because when I teach with courage,
24:33I have the courage to say I am
24:35not an expert on this topic,
24:37but it's important for us to engage in it.
24:41And maybe I have the courage to call on
24:44one I call a console call one of my my
24:48colleagues to Co teach a topic with me.
24:50Or to have a patient join me in rounds
24:53and to talk about their lived experience,
24:57because that then engages
25:00everyone in the conversation.
25:03If I teach with authenticity,
25:05I'm coming to you and saying
25:06I know this can be painful,
25:08this these are my triggers.
25:11This topic triggers me every time
25:12I hear about it because it's always
25:15taught or talked about in a certain
25:17way and it does not take into
25:21account the historical perspective.
25:23So I think authenticity is important.
25:26If I'm teaching with responsibility,
25:28that means I have the responsibility
25:31to read and learn and engage.
25:34That's how I can know I don't need a
25:37trigger warning if I am really doing
25:39the work and I tell you I'm doing the work.
25:43And then always,
25:44always treat the topics with empathy.
25:48Because I don't know who's in my audience.
25:51And so as I think about my role
25:54as a medical educator,
25:57I would say teach with care.
25:59Set a condition where I am in
26:02relationship with students so
26:03that they can come to me and say,
26:06I've looked at the syllabus and
26:08I see this topic is coming up,
26:10can I tell you what this means to me?
26:13Set the learning condition where
26:15we are in an environment where
26:17we can share those stories.
26:20And then I think from an equity standpoint.
26:26It is really important that even
26:29when we're not teaching something
26:31that is specific to HealthEquity.
26:34Everything is HealthEquity.
26:38And if we keep that in
26:40mind as we start to teach,
26:42as we start to engage,
26:43as we do patient centered rounds,
26:46if HealthEquity is at the forefront,
26:49I think we'll more likely than not.
26:53Get better.
26:54We don't necessarily get it right,
26:55but we will get better and we'll
26:58move to a place where we as
27:01medical educators are advancing.
27:06HealthEquity medical education,
27:07but also helping to develop the
27:10next generation of physicians
27:13and physician scientists.
27:23Thank you so much Beverly that
27:24was wonderful and I I really like
27:26how you sort of frame that if
27:28even if we can't get it right,
27:30we can get it better.
27:31And and I think that's a really
27:34aspirational motto to to carry forward.
27:37And so now I am going to,
27:40we're going to shift to zoom and we are
27:42going to hear from Doctor Tia Powell
27:44who directs the Center for Bioethics.
27:46And masters in bioethics program
27:48at Montefiore Health Systems and
27:50Einstein College of Medicine.
27:51She holds the Shoshanna Trachtenberg
27:53frackman chair in biomedical ethics and is
27:56a professor of epidemiology and psychiatry.
27:58Her bioethics scholarship focuses
28:00on dementia, public health policy,
28:02end of life care,
28:04and bioethics education.
28:06She served for four years as
28:07executive director of the New York
28:09State Task Force on Life in the law,
28:11the State Bioethics Commission.
28:13She has worked with the National
28:15Academies of Medicine on many projects.
28:17And served as an advisor to the CDC
28:19and to Health and Human services in
28:21its National Alzheimer's Project Act.
28:23She is frequently invited to speak at
28:25professional meetings including APA,
28:28SBH, AIC,
28:29at medical schools including Einstein,
28:31Columbia, Cornell, Harvard,
28:33NYU, and of course Yale,
28:35and as well as other colleges
28:38including Vassar and Princeton.
28:40She is a board certified psychiatrist
28:42and a Fellow of the New York Academy of
28:45Medicine and the American Psyche Psychiatric.
28:48Association and the Hastings Center.
28:50She holds an undergraduate degree
28:52from Harvard in psychology,
28:53and she received her MD from again,
28:55good old Yale School of Medicine.
28:57So thank you so much,
28:58Doctor Powell,
28:59for joining us and take it away.
29:02Thanks very much.
29:03I'm so sorry I can't be there in person.
29:05It's really much more fun to do that and
29:07I always love coming back to New Haven,
29:09but I am traveling this week and have.
29:12Gotten myself involved in one thing
29:14more than I can handle in person.
29:15So I I present myself by zoom, I apologize.
29:20So I agreed with so much of
29:22what the prior speaker said.
29:24So I want to build on a lot of their on
29:27some of their thoughts and go forward
29:29and I want to center my thinking
29:32with you on the reality of trauma.
29:36We're still in COVID.
29:38A million Americans have died from COVID.
29:4220% of Americans has have lost
29:44a relative or a close friend.
29:46We saw increases in homelessness,
29:49joblessness, domestic violence,
29:50and uptick in mental health
29:53diagnostic diagnosis,
29:54especially in adolescence and young adults,
29:56substance abuse related fatalities.
29:58So this is a reality and it's not like
30:02there's a sort of them to which this happens.
30:05This Is Us.
30:0620% of Americans lost somebody
30:08that deeply cared about improve.
30:11This isn't just a, you know, you know,
30:15something that happens to patients.
30:16We are the patients.
30:19We are the whole community.
30:21So I wanted to center that and I'm going
30:24to quickly summarize where I'm going here.
30:27I'm going to talk a little bit about trauma,
30:29about PTSD.
30:30I'm going to talk a little bit about
30:34how we help students to process.
30:36With normal emotional reactions
30:38and PTSD symptoms, think,
30:40as some have already done,
30:41about what's the role of trigger
30:43warnings and all of that.
30:45And then think with you some more about
30:47what are the issues that all of this
30:49raises about the culture of medicine
30:50and the way it is changing in the
30:52way I think it needs to change some more.
30:55So reality of trauma is
30:57where I'm centering things.
30:59I will say that trauma is really common,
31:02PTSD is less.
31:03So many recover from trauma with time.
31:06But not everyone,
31:08and we don't know looking at any group
31:11who has experienced something deeply
31:15stressful for them in the recent time.
31:17So looking at some recent studies,
31:21about 89% of people in a an online
31:25survey met current DSM DSM 5 criteria for
31:30having been exposed to traumatic events.
31:34Most had been exposed to multiple
31:36traumatic events sort of over a lifetime.
31:39In the lifetime the exposure to traumatic.
31:45Um, let's see.
31:46OK, so PTSD prevalence which is
31:48different than just exposure to trauma,
31:51lifetime is 8.3%,
31:54past 12 months is 4.7%,
31:58and past six months PTSD symptoms is 3.8%.
32:03And actually I think they said that wrong.
32:05Lifetime trauma is 8.3,
32:08past 12 month trauma is 4.7,
32:11and the last six months PTSD is 3.8%.
32:15So this is not uncommon.
32:17I'll say then then I have no tolerance
32:20for the notion that a student who is
32:23suffering from the effects of trauma
32:25is somehow asking coddling of us.
32:27I do.
32:28Students with diabetes who
32:30need insulin demand coddling.
32:32I mean, this is diagnosis.
32:34PTSD is a diagnosis.
32:36So we we need to figure out as
32:39clinicians what is our appropriate
32:41response to somebody who requires
32:44assistance and coddling the word
32:46is such an objectionable. Concept.
32:48It really is intended kind of as an insult,
32:52and intended to say that the assistance
32:55you're asking for is undeserved.
32:57So the question for me is not whether
32:59we should support students who have
33:01issues that they're bringing to us.
33:04Expect uncomfortable feelings,
33:06even PTSD symptoms,
33:08but how we shall support them.
33:10So let me then distinguish a
33:13powerful emotional reaction is not
33:16the same as a diagnosis of PTSD.
33:18It's actually normal and appropriate
33:20to react emotionally to some
33:22of the things you're going to
33:24learn about in medical school.
33:26I actually want you to be angry when you.
33:30Read about and learn about.
33:33The public health implications of redlining,
33:36of racism.
33:36I don't want you to be a blank slate.
33:39You should be angry,
33:40and you should figure how you will
33:43channel that forward in response.
33:45Like we,
33:46our goal is not that you
33:48be immune to the impact.
33:50We are in the business of looking at
33:52things that others find hard to look at,
33:54and it's hard for us, too.
33:55We are in the business of loss and injury,
33:58of mortality, and it's sad.
34:00So the goal is not for you to feel nothing.
34:03Over to feel bad about feeling something,
34:06but to be able to process your feelings in
34:09such a way that you feel safe and feel human,
34:11and importantly, can respond to
34:14your patients as a full human being,
34:17not as an automaton, so.
34:20Trigger warnings,
34:21it definitely have their limits.
34:22I mean, first of all,
34:24we can't use them in a clinical setting,
34:26which is the majority of your training.
34:28When you take a history of somebody,
34:31certainly especially women, but and
34:33it's very especially transgender women,
34:36you will hear about trauma,
34:38people will tell you about
34:40really upsetting experiences,
34:41may just be illness,
34:42but it certainly can be sexual trauma,
34:44violence.
34:45So that doesn't tell us however,
34:48if we should use something
34:50like a trigger warning.
34:51We can do it when we're
34:52sitting in a classroom, right?
34:53So later in the clinic we can't do it.
34:55We'll need to figure out how to
34:56help people in that situation.
34:58But what about in the classroom?
35:00Well, as was already mentioned
35:02by the prior speaker,
35:03if you start digging into
35:05the data on trigger warnings.
35:07There's not a lot of research that
35:09provides good evidence for them.
35:10There's very little research at all.
35:13The few published articles comment
35:15on the lack of high quality research.
35:19In looking through a number of studies,
35:21there were some one typical study sort
35:23of asked students if they thought
35:24trigger warnings would be a good idea,
35:26and they said yes, OK.
35:29That doesn't tell us if they work.
35:30We don't do that with cardiac Cath.
35:32We don't ask the patients,
35:34do you think cardiac Cath
35:35would be a good idea?
35:36We try a real controlled experiment and see
35:39if it actually has a beneficial effect.
35:41So they're looking, you know,
35:44I'm not an expert on trigger warnings,
35:46but looking fairly carefully,
35:48I did not find a rigorously designed study
35:50with a control group that demonstrated
35:53the efficacy of trigger warnings.
35:55And indeed, as mentioned,
35:57there's some evidence that.
35:59And some people,
36:00they actually may enhance anxiety.
36:02I think if this is kind of like,
36:04you know, film makers are
36:06fantastic at eliciting anxiety.
36:08And one of the ways they do it
36:10is to forecast that something
36:12really bad is about to happen.
36:14They make the door sweet.
36:16They start with the scary music.
36:17That's psycho boom, boom, boom.
36:19You know,
36:20all of that stuff is actually to forecast
36:22that something bad is going to happen.
36:25It is not necessarily calming.
36:27And many people find that
36:29it actually doesn't help.
36:30And other people have reported
36:32that when you give that trigger,
36:33people don't report actually taking
36:35that time to prepare themselves.
36:37So there's some troubling
36:38maybe they in some cases,
36:40actually make it worse.
36:42Nonetheless,
36:43I found two really interesting
36:44articles that were specifically in
36:46the context of medical education,
36:48as most of the other studies were
36:50not related to medical school.
36:51There's a nice article by
36:53Gore at all and Med portal,
36:54and if people want I can share
36:57the references afterwards.
36:58And we're at all we're developing
37:00a school at Rush Medical School,
37:03developing a course at Rush Medical
37:07School about trauma informed
37:09treatment for sexual assaults.
37:11They were trying to train medical
37:13students how you would do trauma informed
37:16treatment for survivors of sexual assault.
37:18That's a really difficult topic.
37:20So what they did is that they sent
37:24detailed information about this
37:26course with several sessions.
37:28Ahead of time to the students,
37:29they sent them the role plays in advance.
37:31They warned them we're going
37:33to ask you to participate this.
37:35They also said this material can be
37:37upsetting for a variety of reasons.
37:40You should know that we have
37:42counseling resources.
37:43Here's how you contact them.
37:45And by the way,
37:46if you are uncomfortable or need
37:48to step out during a session,
37:50we totally support that.
37:51We want you to be able to learn
37:53about this and get through it,
37:54and we're happy to accommodate you.
37:56So that is an interesting intervention.
37:58For me,
37:59they didn't do forecasting in class per se.
38:03They sent the message the
38:05information ahead of time,
38:06giving students a private opportunity
38:09for reflection and self preparation.
38:12They also tested at the end and
38:14they found from the beginning to
38:17the end the this course actually
38:19raised student comfort in treating
38:21sexual assault survivors.
38:23So the goal was can you help
38:26other people around this topic?
38:28And actually I thought that was a
38:31really very useful approach and intervention.
38:34There's another article I admired
38:36by Stout and Martin for 2022 in
38:38medical science educator they went
38:41described a number of curricular.
38:43Provisions at University of Indiana and
38:46most medical schools are constantly in
38:48the process of medical school revision.
38:50So they were pro trigger warnings.
38:53They kind of acknowledged that
38:56there really isn't, you know,
38:57strong evidence that they work.
38:59They did say that when we
39:00started doing trigger warnings,
39:01we got fewer complaints than
39:03next year from students.
39:04Again, that's not a study.
39:06It's good that there are fewer complaints,
39:08but I don't know what that means.
39:10They did say some things that
39:12really caught my attention.
39:13They said we want to be able to do
39:16is to model empathy and respect
39:19for the varied experiences of
39:21the people that we work with.
39:24And we would like,
39:25and I'll quote,
39:26to cultivate compassion for others as
39:28an essential part of medical training.
39:31I like the sound of that.
39:33I think that's incredibly important.
39:35So what they set out to do is normalize
39:38emotional response to difficult material,
39:41normalize self-care and courage.
39:42And say that this is actually part of what we
39:46can do to improve the culture of medicine.
39:49So I come to a conclusion.
39:52I think we need to demonstrate empathy
39:55and concern for the experiences of
39:58our colleagues, our students,
40:00and and frankly, of ourselves.
40:02So for faculty, it's not clear to me
40:06that in class warnings are helpful.
40:08I do think it can be done
40:10in such a way that is,
40:12shall we say,
40:13less triggering that you could say.
40:15I acknowledge that these are
40:17emotional topics and that even
40:19some of you may have experience.
40:22I prefer the method of sending
40:24the materials in advance,
40:25encouraging students to look them over,
40:28and then it it gives the students a moment.
40:30I also love the comment about making
40:33ourselves as faculty and as role
40:36models available to our students.
40:38As we hope our students will
40:40be available to their patients.
40:41If this is hard for you, please let me know.
40:44I respect your privacy.
40:46I'm not sure that the students
40:47should feel that they need to tell
40:50the faculty about their experience,
40:52certainly not if they don't want to.
40:54But they should certainly know
40:56that counseling is available.
40:57And frankly we need to know that in our
41:00institutions that the resources are there,
41:02that when the students seek them,
41:04as we encourage them to do that, they
41:06will be met by well trained and sufficient.
41:08Resources.
41:09So for students, what would I say?
41:12Again,
41:12I'm going to say emotional
41:14reaction is normal.
41:15It's not harmful.
41:17It's
41:17different from triggering.
41:18But I don't,
41:19I don't want you to stop feeling.
41:21You know I once as a seal
41:23psychiatrist received a consultation
41:25request from a surgeon because for
41:28inappropriate affect in a patient.
41:30And I went to see the soldier
41:32woman who had had a terrible
41:34neurologic problem and everything.
41:36And she was tearful in describing
41:38that to me and I said, well you know,
41:39your your surgeons worried about you and
41:41and we talked about what was going on.
41:43I concluded at the end of the console
41:45that the surgeon actually found.
41:48Emotion to be inappropriate.
41:50There was no appropriate affect.
41:52It was very uncomfortable with
41:54this tearful patient. Well,
41:55you know what a bad thing happened to her.
41:57Get it together.
41:58You have to be able to hold somebody's hand.
42:00You have to be able to be in that room.
42:02And I'm not saying it's easy.
42:04I myself kind of a crybaby.
42:05It's embarrassing and achieve Christ.
42:08But I would rather that than to suggest
42:11to you that the way a doctor should look
42:15is Stony cold is completely unmoved.
42:19Absolutely unfazed by the most
42:21heartbreaking story that one could imagine.
42:24That's not the goal.
42:25That's not human.
42:26So for students,
42:28I know some of you have been through a lot.
42:31I know you are really challenged.
42:33We are in a business where you have to learn
42:36to see that which others turn away from.
42:38You have a right to need
42:40help and a right to healing,
42:42so faculty should help students at risk.
42:45But I also ask you to watch out for
42:47each other, to really keep an eye on.
42:49Are they?
42:50Your friends and colleagues may
42:51confide in you when they're not
42:53comfortable confiding in the faculty?
42:55I will tell you that I used counseling
42:57services at Yale when I was in Med school.
43:00I went through a very rough patch.
43:01There was significant illness in
43:03my family and potentially fatal
43:05and ultimately fatal.
43:06And right around the time when I was
43:08about to get married, this was coming up,
43:10and I was really under incredible pressure.
43:12And it was really helpful.
43:14And I tell you that because it
43:16is there for you.
43:17And by the way, if it's not there for you.
43:20That's on you.
43:21And there's a very unflattering recent
43:24article, which I will confess to,
43:25of reading in the Washington
43:26Post in the last few weeks,
43:28about Yale not necessarily
43:30supplying adequate responses.
43:31I am not there.
43:32I don't know what the truth of the matter is,
43:33but I can tell you a great university
43:36needs to be ready for this,
43:37needs to be able to care for
43:39the people who are there.
43:40I will also say that we have
43:43fantastic treatments now for PTSD,
43:44way better than we used to have.
43:47Cognitive behavioral training
43:48is pretty awesome.
43:50I'm going to add one more thing.
43:52You guys, if you're students,
43:53you're in the business of figuring
43:55out what's what's your field,
43:57where, what should be your career,
43:59your contribution.
44:00And I'm going to say if some
44:02areas are traumatic for you,
44:04there's no shame in finding a
44:06field where you're free from that.
44:08We just had people discover the
44:10vaccine for COVID that is so far the
44:14greatest discovery of the 21st century.
44:16We still don't have a vaccine for HIV.
44:20If you want to. If you find the lab is
44:22a comfortable place to be, there is.
44:23Beautiful work for you to do there,
44:25and there is absolute wonderful
44:27things that you can do.
44:29But on the other hand,
44:31it may be that your superpower
44:34will be in working in exactly that
44:37domain where you experience trauma,
44:40and I don't want you to give up on that.
44:42You have deep knowledge that you may
44:44be able to use for other people.
44:47I am brought the springs to mind,
44:49one of my personal heroes who
44:51is Marsha Linehan, psychologist,
44:53who was the kind of creator of
44:56dialectical behavioral therapy,
44:58which has been a real game changer.
45:00And the treatment of borderline
45:02personality disease.
45:02And she came out with her own.
45:06Psychiatric history because one
45:08of her patients called her out.
45:10A patient seeing her, you know,
45:11dress for the summer.
45:13So she had scars on her arms
45:15as this patient also had.
45:18And it looked to that knowledgeable
45:19patient like Doctor Lena had in
45:21his history of cutting herself.
45:23And she said it would mean.
45:24All the difference to us if you would
45:27say that you were like us and now
45:31you're better and you have a life and work.
45:34So it really caused her to double down
45:37on her work and but it really that
45:40it was incredibly important that not
45:42just anybody but that she did this
45:44work and talked to people about it.
45:46So if there's something that
45:48you've been through.
45:50I don't want to encourage
45:52you to think that shutting it off and running
45:54away from it is the only choice for you.
45:56It might take great courage,
45:58but as I say, that may be your superpower.
46:00So we want you to think about what's
46:02your gift, what can you really do
46:04that's sort of special to you?
46:06So in conclusion, I'm just going to say.
46:09You know, medicine really,
46:10what needs to continue to work.
46:11And we have made changes in recent years to
46:14accept the humanity of all practitioners.
46:17We are our patients.
46:19We deserve the same kindness.
46:21We don't coddle somebody when
46:23we offer them support.
46:25That is an appropriate reaction,
46:27above all for a clinician.
46:29So we would like to help those who
46:31are suffering, not punish them.
46:33I'm, I'm not necessarily a
46:34fan of trigger warnings.
46:35If somebody wants to do it and that's OK,
46:37I think that's all right.
46:38But I think I prefer for my money,
46:40I prefer the inadvance in your private space.
46:44You think that and then come to
46:45me if you need help and support.
46:46So I will leave it there and hand
46:49things back over to to my colleagues.
46:53Thank you.
47:00Thank you so much Tia,
47:01that that was wonderful.
47:03And I I really like your,
47:05your point about embracing our own
47:07humanity because I think traditionally
47:09that's something that's been at at
47:12times tacitly and at times explicitly
47:15rejected by by the the long and arduous
47:18process that is medical training.
47:20And while certainly we do need to
47:22know how to rein in our emotions
47:24when they become really strong and
47:26might prevent us from acting in
47:28the way we need to act, I think.
47:30We if we rein them in too much to
47:32the point that we're quashing them,
47:34we may also,
47:34we may think that that is making us stronger,
47:37but that actually may be making us
47:39less effective and maybe weakening
47:40us because we can't access the
47:42very things that we're trying
47:44to help in other people.
47:45So thank you so much.
47:47I'm going to turn it over briefly
47:48to mark for a few comments,
47:50and then we're going to hear
47:51from 2 wonderful medical students
47:53that we've invited.
47:59Sure. I'm not going to try and say much at
48:01all after that.
48:02We've heard from the three
48:04marvelous perspectives here,
48:05they're far more intelligent than
48:06anything I have to say about this.
48:07I've learned a lot from this
48:08and I appreciate this.
48:10I guess the one take home message
48:11that I would have or the the the,
48:13the point of view that I bring to this
48:16is primarily as a bioethics teacher,
48:19certainly as a physician and otherwise,
48:21but but as a bioethics teacher and
48:23uncomfortable subjects is where we live.
48:26And when we engage the students
48:28in these conversations,
48:30my take has always been as long as they
48:32are respectful of one another, go for it.
48:34Let's have this conversation.
48:36I think I may need to modify that approach.
48:38I think I've learned a little bit today
48:39that there's more than just respect
48:41that's required perhaps to do this well.
48:44In particularly the the, the,
48:46the words of sensitivity and
48:48empathy came up more than once.
48:50And I think that that's such a big
48:52part of it. And so I think that
48:53respect is an important requirement
48:55for the conversations,
48:56the difficult conversations
48:58we have in the classroom.
49:00But I think maybe we can up our game,
49:02should up our game a bit and pay a
49:04bit more attention to empathy and.
49:06As I'm as you pointed out,
49:07Beverly said, we don't know what
49:09everybody's experience has been.
49:10And when I think so,
49:11a classic subject discussed.
49:13An important subject discussing bioethics
49:15is the moral status of the fetus,
49:17and therefore the ethical
49:19acceptability of abortion.
49:19When you're standing in a room full
49:21of people you don't know who has
49:23been touched by this very seriously
49:25in their lives and who hasn't,
49:26and of course there are some.
49:27We can't know the details of each other.
49:29The better we know each other,
49:30the better off we're going to do.
49:31And I've gotten good advice from a
49:33student friend of mine that smaller
49:34groups are better than larger groups.
49:36For that reason, I mean,
49:38I think that's really helpful,
49:39but I'm not going to try and paint
49:40on this painting except to say that
49:42that I've learned some stuff and I
49:44think that I'll be able to do a little
49:45bit better in teaching bioethics.
49:47But we still have a ways to go.
49:48And with that,
49:49I want to hear from the other
49:50folks and let Sarah take over.
49:52Thank you.
49:55So now we're going to transition.
49:57We have two medical students joining us.
49:59We're going to start with Amber Acquaye,
50:01who is a third year medical student and
50:04also a student whom I have the pleasure
50:07of mentoring on several projects.
50:09She's an amazing writer.
50:11She's very devoted to HealthEquity,
50:14and I think we're all in for a
50:16treat hearing what she has to say.
50:24Hello. So I wanted
50:26to talk about kind of the dual
50:28learning that comes from us being
50:29exposed to traumatic content.
50:31So I think it's not just the
50:33exposure to the content that matters
50:35for preparing future clinicians,
50:36it's the exposure to those
50:38traumatic emotions. So it's not
50:41I think it's that.
50:43We need to learn the practice of how
50:45to navigate the trauma in addition to
50:46learning how do I handle child abuse?
50:49So for graphic content, for things
50:52of nature that are sexual of nature,
50:54for things that relate to injustice,
50:58I don't want my peers to be
50:59facing injustice and feel like,
51:00oh, this is uncomfortable,
51:01so I have to avoid it or this
51:04is uncomfortable so I have to be
51:06emotionally detached from it.
51:07I think the consequence of that is
51:08that we don't teach people to be.
51:11Emotionally connected or compassionate
51:14or fully empathetic providers.
51:15I think if you have to put a piece of
51:18yourself aside to face an injustice
51:19or to face the patient with extreme
51:21social deprivation to get through it,
51:23then you can't necessarily be fully
51:25present for that patient or you can't
51:27fully empathize with that patient.
51:29So it's not just teaching about
51:31child abuse or teaching about like
51:33a trauma informed OB GYN exam.
51:35It's kind of teaching how do I be
51:37fully present for the patients that
51:39I'm going to be with and navigate that?
51:41But the issue is, how do we actually do that?
51:43How do we teach students to ride
51:45the wave of emotions?
51:46And I think that we also have to be
51:49mindful when we're teaching that that
51:51patients or students that come from
51:53marginalized backgrounds are more
51:54likely to be triggered by certain trauma.
51:56So it's we have to balance having
51:59the expectation that we must teach
52:01students about this content,
52:02we must teach them how to navigate it.
52:04But enforcing people into this situation,
52:06we do have people who are going to be
52:08affected by it more than others just
52:10by the nature of the experiences that
52:12they come with. To medical school.
52:13So in order to be mindful of that,
52:15I think there are two things that
52:17we really could do.
52:18I think first starts with acknowledging the
52:20trauma in the presentation and didactic.
52:23Being able to recognize like this
52:24is emotionally heavy or I shouldn't
52:26say that it's just trauma,
52:27but even just the emotional reaction
52:29of facing a difficult subject,
52:31I think there needs to be more
52:33space to acknowledge.
52:34Like, no, you're not crazy for feeling upset.
52:36I too, the presenter,
52:38the fancy MD that you're looking up to
52:40that you came to yield to learn from,
52:42they're also feeling those.
52:43Same things that you are and you are
52:45normal and you are not the only person
52:48in the room feeling that emotion.
52:50I think for me,
52:51a lot of times that triggering
52:52comes in conversations where we're
52:54talking about health disparities.
52:55So I'm the only person in the room and
52:57we're the only black person in the room.
52:59And we're talking about how black women,
53:01you're more likely to have horrible
53:02C-section outcomes and die from
53:04this and lose your baby from that.
53:05And it's sometimes I sit there thinking like,
53:08oh,
53:08are you looking at me to see if I'm reaction,
53:10reacting? Like, do I need to
53:12pretend that I'm tough and not?
53:13Having that emotion,
53:14so they don't think that I'm overly
53:16passionate or here comes Amber,
53:18the one who always wants to talk
53:19about equity, talking about it more.
53:21So I think being able to feel seen by
53:23both the presenters really matters,
53:25but also by peers.
53:27So as an underrepresented student,
53:28I think that's also something we
53:30have to think about is not just
53:32the fact that we maybe are more
53:33likely to come in with trauma,
53:34but the fact that we are less likely to
53:36have that person we can look across the room,
53:39share a look with and feel seen by.
53:41Have that person you can
53:42quickly send that I message to.
53:44And be able to kind of process
53:46and debrief it in the moment.
53:48On top of that,
53:48I think on the side of the instructor,
53:50it's really important or it's very
53:52affirming to me to know that my instructor
53:54or professor is also engaged in the problem.
53:57So just like talking about maternal infant
53:59mortality or maternal mortality impacts me,
54:02because that's me and my family members.
54:04Knowing that you guys are
54:05invested in the problem,
54:06knowing your work on XYZ disparity,
54:09or even just in the sentiment of
54:11how you present knowing that you
54:12actually care means that I know that
54:14you also care about me as a person,
54:16as a learner in that room.
54:18And then on,
54:19in addition to kind of acknowledging
54:21or recognizing the emotional
54:23activation or emotional weight,
54:24I think it's also important to teach the
54:27actual skill of emotional processing.
54:28So not just saying, OK, guys,
54:30we're going to talk about this,
54:31we're going to emotionally trigger
54:32you and we want you to not avoid it,
54:35but not actually give them any
54:36skills on how to do that or
54:37not teach us how to do that.
54:39And I think it's challenging
54:40because a lot of even clinicians,
54:43grown adults,
54:43our parents,
54:44grandparents didn't necessarily learn that
54:46skill of emotional processing in the moment.
54:49So to expect us to just kind of
54:51get that by going through it,
54:53pushing through a difficult conversation,
54:55things a little bit unrealistic or unfair,
54:57especially to students who are
54:58more likely to be traumatized.
55:00So I think there needs to be real
55:02space or real constructed moments
55:04to learn emotional processing.
55:06So maybe a 62nd slide in the
55:08middle of the presentation where
55:10you do a little bit of mindfulness or
55:12after the discussion instead of
55:14going straight to the discussion
55:15questions where we're going
55:16straight into the content of house.
55:18This is how you approach child abuse.
55:20Having a moment of this is how you
55:22emotionally approach child abuse,
55:23or let's let's take a moment to
55:26reflect about how we were all feeling
55:28in response to this and our emotions
55:30as as a consequence of that exposure.
55:32So overall, I would just say that
55:35the learning is not just being
55:36exposed to the content,
55:38the learning is also being exposed
55:39to how to overcome or navigate
55:41through that content.
55:52Thank you so
55:52much, Amber. I think that's really,
55:54you know, to your point about what
55:56do we do about this, your your point
55:58about sort of what what I might
55:59describe as like debriefing strategies,
56:01right, of having this moment
56:02where we talk about this,
56:04where we acknowledge that this is traumatic.
56:06And I also like your point about
56:08feeling seen like it's less about the
56:10trigger warning aspect but more about ICU.
56:13I see that this is trauma.
56:15I'm on your side.
56:16We're in this together and and that,
56:18you know nicely reflects the themes of
56:20empathy that that we heard about earlier.
56:21So thank you so much.
56:23Now we're going to hear from Ryan Sutherland
56:26who was the first year medical student in
56:29my professional responsibility small group.
56:31So that's how I I came to know
56:33him and he's very enthusiastic
56:34and very passionate about ethics.
56:36And so we're really happy to have him
56:38here share his thoughts and insights so.
56:45Thanks so much. So I pulled some of
56:48the first year medical students some
56:50of whom some of whom were here tonight
56:52just to see what their expectations were
56:54on on tonight's conversation as well.
56:57And I think you know if I could put
56:59a title to what this would be it's,
57:02it's a too little too late and
57:04not great and I I think the,
57:06I think the aspect of triggering
57:08and trigger warnings
57:10they have so much potential
57:12you know they're they're there.
57:13As a supportive mechanism of
57:15affirming what students experience,
57:17they're there to create
57:19empathy between professors,
57:20between us and our patients.
57:23But the timing
57:24it sometimes that is off, sometimes
57:27they're not well thought out,
57:30sometimes they're meaninglessly general,
57:31right. So I I sort of compiled some
57:35of the notes that I had from some of
57:36the first year medical students and
57:38I I think I'm in a very interesting.
57:39As you know, we sort of jokingly
57:41refer to ourselves in our classes.
57:43Sort of eggs, right?
57:44We don't know much right now.
57:46We've just started our medical career and
57:49that can be immensely disempowering, right?
57:52We also have a very strange position where
57:55we don't know what we don't know, right?
57:57We don't know walking into
57:59a door what will trigger us,
58:00because we've never been exposed
58:02to that before as medical students
58:03since we're just starting, right?
58:05And in addition to that,
58:07it's very difficult to say to a first
58:09year medical student who very clearly
58:11across the country views medical
58:13education as very hierarchical.
58:14How do you allow a medical student
58:17who might feel maybe awkward saying
58:19no to feel empowered to do so right,
58:21or to take themselves out of a situation
58:23that they might feel uncomfortable with?
58:25So I guess one of the one of the
58:28comments that was made in some of my
58:30questioning of my peers was that some
58:32trigger warnings shouldn't be done at all,
58:34that they're too performative and
58:36performative trigger warnings
58:38just feel meaningless in some way.
58:40I tend to agree with Doctor Powell
58:42about sort of distributing them in
58:44advance and allowing personal reflection,
58:46but while also allowing space and time
58:48in the curriculum to critically reflect
58:51on the things that we're learning so often.
58:54We have schedules.
58:55In our our lectures where we have a
58:5750 minute time clock and we have 10
58:59minutes for break and that lecture
59:00becomes an hour and then all of a
59:02sudden there's no time at all left for
59:04us to critically reflect at all right?
59:07There's also some problems that some
59:09of the students who feel in some ways
59:11tokenized by those discussions too,
59:13where they feel as if they're put on
59:15the spot to sort of share their own
59:17trauma and trauma bond with other
59:19students because they're triggered
59:20by some aspect of this.
59:21Which is why I really think that
59:24sort of inviting personal reflection
59:26before group reflection,
59:28inviting group reflection and maybe
59:29inviting students to not reflect at
59:31all if they don't feel comfortable,
59:33which is fine, right?
59:34Like we we can,
59:35we can also say to students it's, it's OK.
59:37Not to share if you don't feel
59:39comfortable with that right now as well.
59:41I think the repeat reminder of mental
59:44health resources is necessary because
59:45I think there's been a conflation that
59:48trigger warnings are in themselves support,
59:50right?
59:51They're not right.
59:52They're not a substitute for support.
59:54They're sort of preempting that supportive
59:56network that comes after that warning,
59:59right?
01:00:01I also think that I think I said
01:00:03this already,
01:00:04but but insufficient trigger
01:00:06warnings can be immensely damaging.
01:00:08But I do take the the positionality
01:00:10that the trigger
01:00:11warnings in and of themselves can be
01:00:13empowering. They can build agency.
01:00:15I disagree with that notion that
01:00:18they sort of prevent us from
01:00:20developing healthy coping skills
01:00:22or deprive of of us of resilience.
01:00:25I I think that's not necessarily the case
01:00:27I I think it it if anything it opens a
01:00:31communication and trust in the educational.
01:00:33Space and and I think that was both
01:00:35of you that mentioned that which
01:00:37I think is an important thing.
01:00:39But I I do think the aspect of since
01:00:42I don't see patients yet I I've
01:00:44seen several of them only recently.
01:00:47I think in many ways as a first
01:00:49year medical student it it not,
01:00:51it doesn't necessarily trigger,
01:00:53it can obviously trigger our own
01:00:55experiences and bring them to the table
01:00:57but it serves as an asterisk to sort of
01:00:59highlight what we should potentially
01:01:01look for and the patients that we treat.
01:01:03Right.
01:01:03If something is told to us that
01:01:05is potentially triggering and
01:01:06maybe not triggering for us,
01:01:08it might sort of prime US in the future
01:01:10to be well aware of those topics
01:01:12and conversations when they do come
01:01:14up with the patients that we treat.
01:01:16And I think it has a really
01:01:19important educational need,
01:01:20particularly in a culture that I think
01:01:23promotes ethical erosion and burnout.
01:01:25I think it's important for
01:01:27us to remember that humanity,
01:01:28and I think they do, they can humanize us.
01:01:32I think the last thing that I'll
01:01:34just sort of point out which amber
01:01:36beautifully brought up is the fact
01:01:37that I think these discussions
01:01:39need to be problem focused, right.
01:01:41It's it's not enough to just talk
01:01:43about you know whether this sort of
01:01:45initiation of of trigger warning is
01:01:47is appropriate or not appropriate.
01:01:49I think it's,
01:01:49I think it's important to see what
01:01:51what happens after we warn people,
01:01:53right,
01:01:53like are there supportive networks
01:01:54that students can go to?
01:01:55Are there people to talk to?
01:01:57Do students feel that they have the
01:01:59agency to step away from situations that
01:02:01are potentially triggering and I think those.
01:02:03The strategy focused
01:02:04approaches are really key,
01:02:05particularly for students who are
01:02:07early in their medical education.
01:02:08So that's all I'll say.
01:02:10Thank you.
01:02:16Thank you so much, Ryan.
01:02:18We're going to open it up to questions
01:02:20now. I'm going to grab the computer
01:02:22to look for questions on the zoom,
01:02:25but any questions here in person before
01:02:27we start with that or any comments?
01:02:32Oh, you. Yeah. I'll let. OK
01:02:34all right. Yeah. Excellent.
01:02:37So I'll I'll drive it from
01:02:39here then and perfect. And we
01:02:42have a question, we have
01:02:43two questions. Great.
01:02:49Yes, thanks so much.
01:02:50This is a very.
01:02:53Moving topic.
01:02:56I come from a business or corporate
01:02:59background and you've made me think of.
01:03:02Something called organizational design.
01:03:07Or a cultural organizational.
01:03:11Culture design. Uh, whereby the the
01:03:15whole culture of the the whether
01:03:19it's the school or the hospital.
01:03:23It's by design, um. Like that.
01:03:31And that would include.
01:03:34Thinking and implementing.
01:03:37Programs or projects?
01:03:41Uh, or classes or what?
01:03:43Whatever. Um, uh,
01:03:45that are in line with this culture,
01:03:48with this organizational culture.
01:03:51Um. To include triggers to include
01:03:56creating space to include creating.
01:04:00Communication trust to include.
01:04:02And to include how students are choosing
01:04:07are chosen for the medical school.
01:04:10How faculty is chosen?
01:04:13How staff are chosen?
01:04:15Um, so I think I would leave
01:04:18that as a comment for reflection.
01:04:21Because it it seems to me that
01:04:24with the stigmatization especially
01:04:26and the pressure and.
01:04:29Competition.
01:04:32A holistic approach needs to be thought of.
01:04:40That's my comment.
01:04:40Thank you. Would any of the
01:04:42panelists like to respond to that?
01:04:47We have another question here.
01:04:58So if they want to respond,
01:05:00thank you for that talk that was
01:05:02that was really great to hear.
01:05:05I'm just wondering. This might be an
01:05:08obvious question to a lot of people,
01:05:09but how do you decide what is a
01:05:11trigger and what is not a trigger?
01:05:13Because a lot of medical school has a
01:05:15lot of things that can potentially be
01:05:16triggers and blood burns, sexual assault.
01:05:20Abortions a lot of that.
01:05:21So where do you draw the line between
01:05:23what is a trigger and what is not?
01:05:24Because you can't put a trigger warning
01:05:27in everything because it loses its value
01:05:29of every lecture has a trigger warning.
01:05:31So I'm just wondering if you have any
01:05:33thoughts on how to navigate, you know?
01:05:36Getting a sense of what
01:05:37is a trigger for for
01:05:39your audience. OK, that's
01:05:40a great question. Thank you. I
01:05:42I may ask Tia to feel that just because
01:05:45since she is a psychiatrist,
01:05:47she may have a a I'm sure
01:05:48she'll have a better answer
01:05:49than I could give you for that.
01:05:51And then I'll see if our other
01:05:53panelists want to comment as well.
01:05:55I better, I don't know, but I'm
01:05:56happy to, to jump in,
01:05:58I think it's a great question.
01:05:59And you are right,
01:06:01you could get trigger warning
01:06:04fatigue if you opened every session.
01:06:06Comes that way.
01:06:07Just as we have trouble in the
01:06:09electronic health record with
01:06:10people beginning to override sort
01:06:12of warnings and things like that.
01:06:14So as I said,
01:06:15I don't know that they that the
01:06:17classic trigger warning defined
01:06:19in that way is what we need to do.
01:06:23I like the idea of,
01:06:25and I do this actually sometimes
01:06:27my classes of taking a moment after
01:06:30we hear a case presentation or
01:06:32when we talk about a particularly
01:06:34charged issue and sort of take
01:06:36a moment to ask the class.
01:06:37That was pretty I I felt that
01:06:40was really a powerful narrative.
01:06:42How are people doing?
01:06:43And so you can leave some space to find out.
01:06:46It may be that this is a nothing
01:06:48for the people or they they are
01:06:50unmoved by this or they don't
01:06:51want to talk about it right now.
01:06:53But I think you can use some
01:06:55combination of common sense and making
01:06:58yourself available for listening.
01:07:00There are obvious things that
01:07:01we can predict about in advance,
01:07:03but we may not always be able to do that.
01:07:05You may be talking to a student who has.
01:07:08A chronic illness and there they
01:07:10are in medical school and you don't
01:07:13know that by looking at them.
01:07:14So I I think you know, it has to be.
01:07:19And moreover,
01:07:20it won't be the same for every group.
01:07:23So I don't think we can say these
01:07:25four topics require attention in
01:07:27this way and these four don't it may,
01:07:30you know it it may vary from group to group.
01:07:32So I think being available listening
01:07:34and asking people if they want to
01:07:37comment on the emotionality of
01:07:39this material is,
01:07:40is pretty much the the only set of
01:07:43solutions that I can that I can recommend.
01:07:46Thank you. Beverly or Doug,
01:07:48do you want to?
01:07:52Thank you. I I think
01:07:53that is a great question.
01:07:54I guess what I would say is it may
01:07:57be that the the metaphor of the
01:08:00trigger is just the wrong metaphor
01:08:02and that I would be more likely to.
01:08:05The thing I was going to say about
01:08:07the problem with the metaphor is that
01:08:09it can have a a paradoxical effect
01:08:11where someone who wasn't thinking
01:08:13that their reaction would be such
01:08:15that you're actually indirectly
01:08:16pointing them in that direction.
01:08:18And so my instinct would be to have some
01:08:20kind of neutral content descriptor.
01:08:23I'm going to be talking about injuries.
01:08:25I have some slides that you will see
01:08:27some slides of this that or the other
01:08:29and then move on towards it and not,
01:08:31you know,
01:08:32if you're fine if you want to leave,
01:08:33you know all of that is
01:08:35good to be respectful.
01:08:36But I think to include the notion
01:08:39of a trigger in the introduction,
01:08:41I don't know that that does
01:08:43anybody any service that.
01:08:48I would just want to comment on
01:08:50both of the comments because I
01:08:53think they're very closely linked.
01:08:56When you're talking about
01:08:59organizational culture.
01:09:00If you've got the culture set correctly,
01:09:04if you have it right.
01:09:06It in it by definition encompasses
01:09:10the content and something
01:09:13that both Amber and Ryan.
01:09:16OK. I'll discuss,
01:09:18which is space in in the curriculum,
01:09:23thinking about your learners,
01:09:25all of that, they're inextricably
01:09:27linked together if the culture is right,
01:09:30if the culture is set.
01:09:32And so I I think that getting
01:09:36to your it's who's in the room,
01:09:38who are your educators,
01:09:40but what is the content?
01:09:42And then how are people
01:09:44approaching that that's all about?
01:09:47Culture and culture of the
01:09:48institution and how we do that,
01:09:51if we really are going to do better,
01:09:54it can't be isolated.
01:09:55Trigger warnings.
01:09:56It's a as I started off,
01:09:58it's bigger than that.
01:10:00It's really about medical
01:10:01education and equity in all of
01:10:04these issues tied up in culture.
01:10:10Beautifully said. Thank you so much.
01:10:13Other questions from the live
01:10:14audience or let's take one more
01:10:16and then I'm going to go to zoo.
01:10:24A couple of thoughts.
01:10:28Is it on?
01:10:33OK.
01:10:37This is a great talk.
01:10:38I think it brings up for me as a
01:10:42nurse what prompts people to be
01:10:45attracted to the medical field.
01:10:48To the nursing field,
01:10:50in my experience, a lot of us went
01:10:54into the field because of trauma,
01:10:57because of our emotional experiences,
01:11:02because those are relationships
01:11:05and relationships. Drive.
01:11:09So much of our personhood.
01:11:14So I think that's an interesting thing to me,
01:11:18why people choose the professions.
01:11:21Second of all,
01:11:23what about people who have
01:11:28not acknowledged their trauma?
01:11:30And.
01:11:33Are given warnings and you know it.
01:11:37It hasn't really connected
01:11:39for them. So do they.
01:11:43Get traumatized at some point
01:11:47unexpectedly because that trauma's
01:11:51been blocked. Because that.
01:11:53Can be how trauma comes out
01:11:55is when you least expect it
01:11:58and get triggered that way,
01:12:00and So what are the?
01:12:03Repercussions in a classroom
01:12:05regarding that. Yeah.
01:12:09Any comments from the panel?
01:12:13It's more of a reflection.
01:12:15Thank you so much for for sharing
01:12:18that with us. I'm going to.
01:12:21Sorry, I'm going to take a
01:12:23question from the Zoom now.
01:12:24How do we
01:12:25balance the fact that patients
01:12:26might find allies within their providers
01:12:28lived experiences with potentially
01:12:30losing professional opportunities?
01:12:31Because we still live in a world
01:12:34where experiencing trauma is
01:12:35often seen as a detriment to those
01:12:37doing the hiring or promoting.
01:12:38For example, in the last few years
01:12:40I witnessed an admissions committee
01:12:41member saying applicant who spoke
01:12:43frankly about her journey through
01:12:44an Ed say that it was proof she
01:12:46wouldn't be able to handle a
01:12:48stressful career in medicine.
01:12:55Oh, Tia.
01:12:58Yeah, I I'm sorry to say,
01:13:00I think this remains a real issue,
01:13:03an issue for any sort of trauma.
01:13:05But I think we still have significant
01:13:10bias against anybody who admits
01:13:13to a psychiatric diagnosis,
01:13:15admits to a history of substance use.
01:13:18So I think to talk about.
01:13:21Your experience in either of those domains
01:13:24and and probably other ones as well,
01:13:26even a significant chronic illness
01:13:29is enough to get people dinged
01:13:32for residency applications.
01:13:33And I'm, I'm sorry that that's true
01:13:36and I I don't think we're changing fast
01:13:39enough so that I actually think that Umm.
01:13:44We have to acknowledge that medicine
01:13:49is coming from someplace and it's
01:13:52we hope that it is changing and
01:13:54that we try to be part of the
01:13:57change and hope that they will be.
01:13:59But that they actually may still
01:14:01need to be discreet about some
01:14:04issues particularly in high high
01:14:06value processes like interviews
01:14:08for for moving forward and that
01:14:10kind of thing that you really.
01:14:14Cannot assume that everybody uncomfortably.
01:14:19Hear this and I I've heard this
01:14:22with lots of different students
01:14:24who have presented openly as trans,
01:14:27sometimes have had great results.
01:14:30Some people have been dinged.
01:14:33So I think there are all sorts of
01:14:36different differences among us and you.
01:14:38Still, unfortunately,
01:14:39need to be careful about what you
01:14:43lead with when you're in a very
01:14:47high profile evaluative situation.
01:14:50I hope that during your training you
01:14:54will be able to build relationships
01:14:56with people who you can go to
01:14:59for counseling can sort of say,
01:15:01listen, this happened to me,
01:15:03should I write this in my residency essay?
01:15:06Should I talk about this in my interviews?
01:15:08It's part of why I'd like to be a doctor.
01:15:10I think it adds to my knowledge and
01:15:13and get some counseling about your
01:15:15particular story from people that you
01:15:17trust before you go forward with it.
01:15:19And and I I would say we cannot probably
01:15:22I I wish I could say differently
01:15:24but I think you cannot expect that
01:15:26you should be able to tell intimate
01:15:28details about yourself and have
01:15:30everybody treat them respectfully.
01:15:32And I hope the other panelists
01:15:33will disagree with me.
01:15:34But that's kind of where I come down
01:15:36having seen some students injured by.
01:15:39Um, revelations?
01:15:44Other thoughts you wanted to share? Go ahead.
01:15:49I will not disagree.
01:15:52One it just brought to mind.
01:15:53Mark one of the things you
01:15:55say in your first lectures
01:15:56to 1st year students about
01:15:58the profession. We are
01:15:59also sort of self policing.
01:16:02We monitor ourselves as a profession and
01:16:07and as such we choose ourselves right.
01:16:10We choose people who are like us.
01:16:13And and that sets us up.
01:16:17For everything that's not
01:16:19like us being the other.
01:16:21And getting excluded and
01:16:23then if we don't have.
01:16:26People with who've had these emotional
01:16:28experiences who come into the room
01:16:30that we can recognize, right?
01:16:32There's some emotions we accept
01:16:33because we can see it in ourselves,
01:16:35but there are others that we don't.
01:16:37I I think that adds to this the
01:16:40difficulty of the institutional
01:16:42culture of trying to change.
01:16:45Because if it's just us being
01:16:48ourselves selecting ourselves that
01:16:51that is not a recipe for for change,
01:16:55or widening our tent so that
01:16:57we can have people with
01:16:58more and varied experiences
01:17:00in the profession.
01:17:04Thank you.
01:17:06Thank you, Beverly.
01:17:07I guess the only thing I I would want
01:17:09to add to that is that I think there's
01:17:11a tendency to think that this issue
01:17:15is to be addressed when it happens,
01:17:17and no doubt it is,
01:17:19but I think we would be in a better
01:17:22position if we were more mindful.
01:17:24You know, I, I really like, Ryan,
01:17:26your comment about too little,
01:17:28not enough and not that great.
01:17:31And to me that speaks to the fact that we,
01:17:33we haven't done the job we ought to be
01:17:36doing from the beginning so that we're
01:17:38not putting out fires all the time.
01:17:40But what we're,
01:17:42we're doing is trying to create
01:17:44the conditions under which people
01:17:46feel they have the confidence to
01:17:49navigate when those situations arise.
01:17:51I don't know exactly what that looks like,
01:17:54but I'm pretty sure it's not
01:17:55there at the moment.
01:17:57Thank you. We
01:17:59have another question in the audience.
01:18:04Thank you. First
01:18:06off, thank you. Thank you everyone
01:18:08for fantastic and personal insights.
01:18:10But one question that I have
01:18:12that has been I think echoing
01:18:14through a lot of the speakers is.
01:18:18The discussion of size of the group,
01:18:21but especially as far as that
01:18:24rate relates to the ability or the
01:18:27unpredictability of peers to trigger
01:18:29each other during our content.
01:18:32It's enough to try to support
01:18:34and create an environment where
01:18:35you are mindful of the learners.
01:18:37But it's a very,
01:18:38another very different thing for
01:18:41what one student finds casual
01:18:43or triggering to suddenly trip
01:18:45trigger or not a different student.
01:18:48And so that can have kind of
01:18:49a reverberatory effect.
01:18:51I wonder if anyone could speak a
01:18:53little bit to how to create a more at
01:18:58an institutional or environmental level.
01:19:01Comforting or or compensatory environment
01:19:04to correct for that kind of scenario.
01:19:11I could take a crack. I could take
01:19:13a crack at that too, unless somebody else.
01:19:15So I think that's such a thoughtful comment,
01:19:20I think. We are in my view,
01:19:24and maybe this has always been there,
01:19:25but I think we have come to
01:19:28a point where there are many
01:19:30fractures in civil discourse where,
01:19:33you know, there's so many.
01:19:36Inflamed arguments that you can't
01:19:38talk about politics at all.
01:19:40If you don't know somebody, you can't.
01:19:42You know, I just, I was.
01:19:44I got off the subway in New
01:19:45York City the other day,
01:19:46and I was wearing a mask because I
01:19:48usually wear a mask on the train still.
01:19:49And somebody laughed at me.
01:19:51I'm clearly an older woman.
01:19:53I'm walking on the street.
01:19:54I'm wearing a mask. Like, wow. Like.
01:19:58What? What does it do to you then?
01:20:01I'm wearing a surgical mask,
01:20:03so just like so I think.
01:20:06Part of our education is that
01:20:08we can't afford to do that.
01:20:10As physicians, as clinicians,
01:20:12you will need to care for people
01:20:15who are very different from you.
01:20:17So you need to be able to hear
01:20:19difference and to find a way to
01:20:22maintain civility with people who
01:20:23are quite different from you.
01:20:25And that needs to start in our
01:20:27classrooms so that if somebody
01:20:29does share something or talk about
01:20:32their experience,
01:20:33it's extremely important that they not be.
01:20:36Kind of slammed down by their peers.
01:20:39That's stupid. That doesn't happen.
01:20:41I never heard of that. I never saw that.
01:20:43I never experienced that.
01:20:44You really.
01:20:45I want one of the things that I'm.
01:20:48I'm embarrassed to admit.
01:20:49One of the things I most remember
01:20:51from all my psychiatric training
01:20:52was a joke supervisor once made,
01:20:54which is 2 ears, one mouth.
01:20:56You should always listen more than you speak.
01:21:00So I think it's great in the
01:21:01classroom for the students to begin
01:21:03to show that respect to each other.
01:21:05If you don't find somebody's.
01:21:07Experience consistent with your own.
01:21:09Then you have learned something
01:21:10from your peer,
01:21:11and you need to deal with that respectfully.
01:21:15Go ahead, you have another comment. OK.
01:21:19Thank you so much.
01:21:21Any other questions in the audience,
01:21:24Ben? Can we get? I'm sorry,
01:21:28I thought Karen had the mic.
01:21:29We've got one right here.
01:21:33A couple of folks have
01:21:35alluded to this, but you know,
01:21:36I was just looking at the literature
01:21:39before before this talk and
01:21:41they're actually, I think 6
01:21:44randomized trials of trigger
01:21:45warnings and. You know it's it's
01:21:48it's a fairly. Extensive literature
01:21:51at this point, there are thousands
01:21:52of patients enrolled in randomized
01:21:53trials with and without trauma.
01:21:57Students and and and participants
01:22:01taken from the general population.
01:22:05And all all of the randomized
01:22:07trials show no benefit, and some
01:22:10show maybe a small worsening of
01:22:13anxiety or other negative affect.
01:22:16It seems to me like we like.
01:22:18We've actually looked pretty well
01:22:20at at the at trigger warnings at
01:22:22this point, and they don't work.
01:22:25Umm. I'm. I'm curious.
01:22:27I I think there's been some.
01:22:30Touching it at that, I'm
01:22:31curious to hear your thoughts directly.
01:22:34So certainly so I I'm not particularly
01:22:37familiar with the literature, but all of
01:22:40that makes entirely intuitive sense to me.
01:22:45I I I guess what I would say is you
01:22:48know the interesting question to me
01:22:50is given that that seems to be what
01:22:54the empirical evidence suggests why
01:22:56is it that we you know why is it
01:22:58we feel attached to this particular
01:23:01mechanism and I you know I would
01:23:04posit that we haven't figured out yet
01:23:06what we need to do that's better it
01:23:09seems like it's a a kind of just an
01:23:12easy not easy but a reflexive go to.
01:23:15Mechanism and as I I suggested. To my mind,
01:23:21the usefulness of the trigger warning,
01:23:22particularly for this kind of discussion,
01:23:24is that it opens the door to try and
01:23:27figure out what's going on behind it.
01:23:29I I I am.
01:23:30And it it also seems to me,
01:23:33in the experience I had that
01:23:35I related earlier,
01:23:36is that in both examples trigger warnings
01:23:39were given and yet there was no for
01:23:43somehow that hadn't been absorbed.
01:23:45So that to me was a clue that the trigger
01:23:47warning itself was not the issue,
01:23:49it was something greater.
01:23:51And that's why I think this kind
01:23:53of conversation is very helpful,
01:23:54because it's still a little bit mysterious,
01:23:57the sort of meta theme that comes
01:24:00to me from the responsive. Is that?
01:24:04Trauma may not be the way to think about it.
01:24:06The way to think about it is about
01:24:08relationships and where people are close,
01:24:10where there is trust,
01:24:12where there is an openness to listen
01:24:15and be receptive to others there.
01:24:18I get the feeling we're moving
01:24:19in the right direction.
01:24:20How that gets institutionalized,
01:24:22how it creates the culture
01:24:24of an organization,
01:24:26how it gets incorporated
01:24:27into medical education.
01:24:29I think that's what we need to work on.
01:24:36You you you see it away from the word easy,
01:24:39but I think actually trigger
01:24:42warnings actually. Are easy.
01:24:45It keeps us from having to do more work.
01:24:49Because. The more work. Is.
01:24:54The responsibility of of broadening the
01:24:58perspective of being prepared to talk
01:25:02about we talk about difficult things,
01:25:05but if we talk about difficult
01:25:07things in a way that respects and
01:25:11empathizes with our learners.
01:25:14We think, we, I think we may think
01:25:16it is going to take more time.
01:25:19We need the reflective time.
01:25:22Who's going to be the person
01:25:24the go to if things break down?
01:25:27We we don't feel comfortable managing
01:25:30our our groups if that happens.
01:25:32And so I think the trigger warning
01:25:35is a stand in saying I'm just,
01:25:37I'm flagging this for you.
01:25:39Because the other side of that
01:25:42is much harder, much deeper.
01:25:44And so we keep doing it,
01:25:47even though there is evidence
01:25:49that has minimal effect,
01:25:51as I said in my in my comments.
01:25:54And so I think that.
01:25:57Taking a more holistic view of
01:25:59how and what we're teaching,
01:26:01listening to what the students are saying,
01:26:04they're telling us clearly that the
01:26:07trigger warning in and of itself
01:26:10is not enough. We need to do more.
01:26:13And so it we need a we the substitute
01:26:19is is harder, more difficult,
01:26:21but ultimately is going to be what is
01:26:25needed if we are really going to to
01:26:28really teach our learners how to not only.
01:26:32Deal with the content,
01:26:35but as Amber alluded to.
01:26:38Understand how to emotionally
01:26:40process the information.
01:26:41That's a much bigger proposition than
01:26:43two lines at the beginning of a talk.
01:26:49Really. Well said.
01:26:50Umm, you know what, what I'm hearing
01:26:53from from you and from from our,
01:26:55our panel is that it's, you know,
01:26:57when we think about trigger warnings,
01:26:59that's really a, a warning about content.
01:27:02But the issue at hand
01:27:03isn't so much the content.
01:27:05It's the context, it's the culture,
01:27:07it's the it's it's the,
01:27:09the milieu in which students who
01:27:11may be coming from places of trauma
01:27:13are encountering this content,
01:27:14and if that's in a way where they don't feel,
01:27:17like you've said, safe and supported.
01:27:19That can feel re traumatizing and to be
01:27:23fair as you know as we've heard tonight
01:27:26part of being a physician is
01:27:28encountering really difficult
01:27:30situations sometimes without warning.
01:27:32But students aren't physicians yet.
01:27:34It's our job to help them become that.
01:27:37And so I think when we send them the
01:27:39message that we're in their corner
01:27:40and that we want to help them get
01:27:42to a place where where they can sort
01:27:45of build up that from a safe place,
01:27:49from a place where they feel like.
01:27:50We have their back.
01:27:52I think we only prepare them
01:27:54better than to to go forward.
01:27:57So I just I this was a wonderful
01:27:59panel we have just two minutes left.
01:28:02So you know it's typically our
01:28:04tradition is if anyone has any final
01:28:06thoughts on our panel or if if our
01:28:08wonderful students have any final
01:28:10thoughts they'd like to share before
01:28:12we close I I'd love to hear them
01:28:15but I I think you know this is has
01:28:17been a really wonderful evening any.
01:28:22Last minute.
01:28:25No. OK, wonderful. Well, I really,
01:28:28really appreciate our wonderful panelists.
01:28:30Dr Shears, Dr Shenzen, Dr Powell,
01:28:34Amber Acquaye, Ryan Sutherland,
01:28:35thank you so much for sharing
01:28:37your insights as well.
01:28:38We really appreciate it.
01:28:40Thank you to everyone who
01:28:42attended in person and in zoom.
01:28:44There's obviously a lot of work that
01:28:46remains to be done in this field,
01:28:48but I think this is an important start.
01:28:50And I I know I too like Mark.
01:28:52I've. I've had a lot of.
01:28:55I have a lot of reflecting to
01:28:57do and this is really really
01:28:58helped me and so I'm I'm very
01:29:00grateful and I thank you so much.