Taking a Trauma-Informed Approach to Medical Education Research

You are halfway through the interview, your first as a budding qualitative researcher. The medical student across from you starts to answer your question about the struggles of being displaced during their training due to war, when they pause and begin to cry. They ask to end the interview, and you are left wondering: “Did I just cause harm?” 

As the field of health professions education has matured into an independent domain of scientific inquiry, researchers have increasingly adopted subjectivist research paradigms and qualitative methodologies. Interviews are now commonly used to ask research questions related to beliefs, values, and experiences. More recently, the growing awareness of disparities in health and education outcomes in the United States has led to a concurrent rise of researcher interest in fostering representation, fairness, and belonging in medical education. This marriage of methods and interest offers an opportunity to restructure education to be more responsive and inclusive by centering on the experiences of the learner. However, while we may have good intentions in seeking to uplift the voices of those from historically marginalized or underrepresented backgrounds, certain lines of inquiry may explore stories of trauma and run the risk of causing harm. 

A core ethical principle of research is non-maleficence, the duty to do no harm. Medical education research, especially qualitative work, often is labeled exempt or not human subjects research by institutional review boards, which may give a false sense of security that our methods, such as interviews, are “safe.” If we do not adequately prepare ourselves to avoid potential re-traumatization among our research participants, we may indeed cause harm. 

 Trauma-informed care offers a model to sensitively explore experiences that may have been traumatic. Trauma is defined by the Substance Abuse and Mental Health Services Administration (SAMHSA) as resulting from “an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual’s functioning and mental, physical, social, emotional, or spiritual well-being.” This understanding has evolved from our use of trauma and post-traumatic stress disorder in the 1980s to describe the experiences of combat veterans to a much broader and more inclusive phenomenon. Alongside this has been the refinement of the trauma-informed approach by fields including mental health, harm reduction and substance use, and social work. If we are to continue exploring topics that may have been traumatic for our participants, then it is imperative for us to similarly adopt the trauma-informed approach to our research. 

A trauma-informed approach to medical education research acknowledges that our participants may have experienced trauma, adopts a broad and empathetic definition of trauma, prepares to prevent or mitigate re-traumatization, and has a plan to respond to unintentional harm. The SAMHSA defines six key principles to a trauma-informed approach, adapted below to the context of medical education research:

We can use these principles—with forethought, honest self-reflection, and flexibility—to perform safer qualitative research. To illustrate this, I will go through several practical recommendations for planning and performing interviews, as they represent a large proportion of qualitative data collection instruments. 

Reflexivity is a key component of rigorous qualitative research and is vital to a trauma-informed approach. Researchers must continuously reflect on their personal identities and positionality to their work if they are to begin to address personal biases and to share power with their participants. To do this effectively, the team should familiarize themselves with the impact of various systemic forces on their population of interest. A member of the studied community on the research team can help equalize the power hierarchy, provide context during team discussions, and co-construct knowledge. 

Researchers should be transparent and strive to share power throughout the research process. Consider adding a warm-up conversation prior to the interview itself to build rapport, set expectations, and answer questions. Stress that participants can pause, skip questions, or end the interview at any time. As part of this warm-up, you can preview what will be discussed and allow participants to ask clarifying questions or decline to participate. Some researchers share the interview guide with participants ahead of time, so they can emotionally prepare. Inquire about practical details that can make a participant feel safer: Will the interview be over phone, video conference, or in person? If in person, where will the interview be held?

 Finally, the team and study protocol must remain flexible. During individual interviews, the interviewer should be ready to pivot to avoid re-traumatization. However, participants affected by trauma may desire a space to share instead of pivoting away immediately. In these cases, listen actively, validate, and give space, rather than pushing for more details. Give the participant the power to change the topic when they are ready. In the case of harm or the unveiling of psychological, emotional, or physical needs, it is better to have a plan in advance, like referring to mental health resources or connecting participants to other relevant supports. Perhaps the most important action a team can perform is to pause or end a study to redirect resources to redress harm. 

 Rigorous, critical medical education research has the potential to dismantle inequitable systems and rebuild them upon a foundation of fairness and inclusion. However, we must strive to act with humility through this work, and deliberately share power with our participants in order to avoid perpetuating harm. A trauma-informed approach to research is not only feasible, but necessary if we are to demonstrate our commitment to meaningful change and structural accountability in action and not just words. 

Alexander Garrett, MD is an Acting Assistant Professor of Emergency Medicine at the University of Washington School of Medicine. His areas of professional interest include qualitative research methodologies, equity in medical education, and the experiences of students who are the first in their family to attend college. Alex can be contacted via email.