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Michigan Trauma-Informed Medical Education (M-TIME): Using Evidence-Based Practices to Train the Next Generation of Physicians in Trauma-Informed Care

Before medical school, I worked as a crisis counselor at a domestic violence shelter in rural Michigan. I saw the lasting effects of trauma and its manifestations on health, and quickly realized my passion within medicine: trauma-informed care (TIC).

TIC is a framework of medical practice that promotes autonomy, safety, empowerment and healing, and that recognizes individuals are more likely than not to have experienced at least one traumatic event during their lifetime (to be exact, research shows 89% of U.S. adults have been exposed to trauma). TIC is essential for clinicians because trauma has been documented to have deleterious impacts on health; these events can lead to difficulty accessing medical care, remaining engaged in treatment plans, and feeling psychological safety when receiving care. 

At the Duderstadt Center on U-M’s engineering campus advocating for survivors of sexual violence.

Despite this, education on TIC in medical schools across the U.S. is largely absent, and upon starting my M1 year at UMMS, I quickly realized that our first-year clinical skills course did not include any instruction on TIC. However, a special characteristic about UMMS is how receptive the faculty and staff are to curricular improvement, especially regarding strengthening social justice and humanism as key pillars. The clinical skills course leadership immediately responded positively to my advocacy for inclusion of TIC in the curriculum, and asked me to use my prior work and research experience on trauma and TIC to design, implement and evaluate an evidence-based TIC workshop to be completed by all M1s in the fall of 2021. Excited to dive into this medical education project, I enrolled in the Scholarship of Learning and Teaching (SoLT) Path of Excellence program, which allowed me to engage in structured medical education training on a regular basis during my M1 year. 

The culture of mentorship at UMMS is second to none, and I had the pleasure of working on my project with the close mentorship of Dr. Lauren Owens, a faculty member in the Department of Obstetrics and Gynecology. In forming this team, known as Michigan Trauma-Informed Care Education (M-TIME), I also partnered with my incredible classmates Luca Borah, Stephanie Terrell and Elizabeth Erkkinen, each of whom has work experience in trauma-informed care as well. The foundation of our project involved working with LaTeesa James, a health sciences informationist at UMMS’s Taubman Health Sciences Library, to conduct a formal scoping review of the empirical literature on TIC curricula in the health professions. Sifting through more than 1800 articles, we identified the 51 articles meeting review inclusion criteria and quickly got to work synthesizing the strengths of these programs for use in the UMMS TIC workshop.

To support myself financially during the summer between M1 and M2 as I completed this project, I applied for and was awarded the $1,000 M1 Summer Impact Accelerator grant through the medical school. I also knew that part of my project would be designing a retrospective pre-post survey instrument to capture comprehensive data about the workshop’s efficacy and collect narrative feedback from the M1 students about areas for improvement. To maximize survey response rate, I was awarded a $2,000 Capstone for Impact grant through the medical school; this enabled me to provide a $10 gift card to a beloved local coffee shop, Sweetwaters Coffee and Tea, to every single M1 student who completed the survey after the TIC workshop. In implementing a participant survey, I also wrote and submitted an application to the university’s Institutional Review Board (IRB), the first of many IRB applications to come in my career. 

At the Nobel Peace Center in Oslo, Norway after giving a podium presentation at the European Conference on Domestic Violence.

The TIC workshop took place in October 2021 and was a huge success! The workshop components included: (1) a didactics portion emphasizing the link between trauma and health outcomes, best practices for trauma screening within patient encounters, and physician vicarious trauma; (2) a case-based session to practice TIC skills in small groups; and (3) a structured debrief. For statistical analysis of my survey instrument data, I partnered with a statistician at RISE (Research, Innovation, Education, Scholarship), a hub for medical education innovation at Michigan Medicine. I am so happy to share that 129 out of 170 M1 students completed the survey (75.9% response rate) and that our analysis illustrated statistically significant (p < 0.001) increases in students’ knowledge of TIC, intention to integrate TIC into their future clinical practice, and confidence in TIC skills. Moreover, narrative survey responses showed an overwhelming desire for increased curricular time devoted to TIC in the future. 

Now that the workshop has concluded, I have shifted my attention toward disseminating the results of this project and am beginning to conceptualize improvements to the TIC curriculum for next year’s entering class. With mentorship from Dr. Owens, I have written several first-author publications about this work, and have greatly enjoyed connecting with trainees and physicians around the country who also study TIC in medical education.

With my medical school partner in crime, classmate Jacqueline Lewy, who provided the most amazing support and sounding board as I completed my project.

The success of designing, implementing and evaluating an evidence-based curricular intervention for 170 first-year medical students relied upon the unique constellation of resources and support available to UMMS students, including: (1) the SoLT Path of Excellence and steady stream of individualized advice from enthusiastic Path advisors Drs. John Burkhardt, Dan Cronin, and Caren Stalburg; (2) LaTeesa James, a health sciences informationist at the Taubman Health Sciences Library; (3) the $1,000 provided by the M1 Summer Impact Accelerator and $2,000 provided by the Capstone for Impact grant; (4) the statisticians at RISE; (5) the mentorship by faculty member Dr. Owens; (6) the assistance of my classmates Luca Borah, Stephanie Terrell, and Elizabeth Erkkinen; and (7) the enthusiasm of the first-year clinical skills course staff for curricular innovation and improvement. 

All of this is to say that at the University of Michigan Medical School, if you can dream it, you can do it. The faculty and staff here at UMMS enthusiastically champion student projects — my TIC curricular intervention is a true testament to that.

Creating Impact through the Luke Clinic Baby Book Project

I started volunteering at The Luke Project 52 Clinic at the beginning of the Branches curriculum, during my 3rd year of medical school at the University of Michigan. One of my good friends and recent alum, Dr. Meghan Rowe, had chosen the clinic for her continuity site, so she would make the drive every other week for her last two years of medical school. Living in Detroit for a month-long rotation with the Detroit Public Health Department, I decided to join in one day and see if I could help out. I realized immediately how incredible this organization is. The Luke Clinic was founded to address the high rates of infant mortality and health disparities in Detroit and surrounding areas. They offer free prenatal, postpartum and infant care to any family in Detroit, and most patients are under- or un-insured. The cornerstone of Luke Clinic’s philosophy, which the clinic co-founders Brad and Sherie Garrison emphasize, is the relationships providers build with the families that visit. The clinic seeks to offer support and care for new parents at what can be an incredibly transformative and vulnerable period in someone’s life.

The Luke Clinic Mobile Van – photo credit to Meghan Rowe.

The clinic noted that, due to limited access to medical care, some children may go months to years without regular check-ups. When they do see health care providers, factors such as housing instability make it challenging for children to stay within the same health care system, and it can be hard for providers in different systems to closely monitor child growth and development. Pediatricians keep track of children’s growth and development, including meeting milestones such as having a social smile, learning to say some words, or sitting independently. When health care providers notice a child may be behind in one or more developmental milestones, early interventions can make a big impact to ensure that children grow to their full potential.

To address this need, Dr. Rowe started working on the Luke Clinic Baby Book for her capstone project. She talked with new parents and staff at the clinic to create the very first prototype – an illustrated book with space to keep track of basic health information such as height and weight, educational information for parents on developmental milestones, and plenty of space for pictures to make the book fun. After her graduation, since I loved visiting Luke Clinic so much, I continued this project as part of my Capstone for Impact (CFI) in the Branches. I have been able to bring my creative experiences from every step of my education into this project.

Some pages we designed for the Baby Book.

As a high school newspaper editor, I spent a lot of time working with Adobe InDesign and was thrilled to transfer the book into InDesign to create a visually appealing and beautiful workbook. As an engineering major in college, I took many classes with our school’s design department and utilized many of these design skills in development of this book. As a medical student applying into pediatrics, I have learned so much about child growth and development, and the common challenges new parents at the clinic face, incorporating this knowledge into the book using accessible and plain language. I’m thankful that CFI supports the opportunity to take creative risks. My process of developing the book included printing out Meghan’s first prototype, seeking user feedback by talking with new parents waiting in the Luke Clinic lobby, and meeting with nurses, doulas and physician staff at the clinic to identify needs. I then got the chance to create and illustrate the health education materials and re-organize the book for a second prototype.

Each member of the health care team offered important thoughts on how to make this book relevant and useful. New parents were excited to have space for baby pictures, to write down their questions and keep track of important phone numbers. They wanted information on how to feed their baby in their early days and when to call the doctor. Clinic staff and providers shared thoughts on how to present health education materials in a way that was accessible but not scary— for example, while the average child will pull up to stand by age one, it is not unusual for a one-year-old to still be learning this skill. I hope to translate this book into Spanish and Arabic for the clinic’s families, print it to be both durable and enjoyable to use, and distribute it to new families at the clinic. I would like to evaluate how families use the book in the future and would also very much love to share the digital file with anyone else who may be interested in this resource!