The Ethics of Trigger Warnings

December 09, 2022

December 7, 2022

Douglas Shenson, MD, MPH, MS, MA

Tia Powell, MD

Beverly Sheares, MD, MS

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ID: 9263
To Cite: DCA Citation Guide

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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.