A Pilot Study on the Awareness and Knowledge of Adverse Childhood Experiences Science and Trauma-informed Care among Medical School Students



 

Jere Tan, BS1; Shanta R Dube, PhD, MPH2

Perm J 2021;25:20.285

https://doi.org/10.7812/TPP/20.285
E-pub: 07/28/2021

ABSTRACT

Background: Childhood trauma is widespread and contributes to clinical, behavioral, and social health consequences. Despite more than 2 decades of research from the Centers for Disease Control and Prevention–Kaiser Adverse Childhood Experiences (ACEs) Study, ACEs science is still not fully integrated into medical school curricula. Therefore, we conducted a pilot study to assess the level of awareness about ACEs and trauma-informed care (TIC) curricula among medical students.

Methods: A cross-sectional study was conducted at the Medical College of Georgia using a sample of convenience. Enrolled first-, second-, and third-year students were invited to complete a survey during the Spring 2020 semester. A total of 194 students responded to specific questions about training on and knowledge of ACEs and principles of TIC.

Results: The majority of students (80%) indicated they heard of the ACEs Study, and 70% reported they received information about ACEs. Regarding TIC, findings indicated less knowledge on cultural context related to stress and trauma. In addition, first-year students were less likely to know about TIC principles than third-year students.

Conclusion: This preliminary study is the first of its kind in the state of Georgia, where recent surveillance data indicate that 60% of adults have experienced at least one ACE. Given that ACEs are widespread, effective educational practices to increase knowledge about ACEs science, and skills to carry out TIC practices may benefit future practicing physicians by introducing ACEs in the first-year curriculum.

INTRODUCTION

After more than 2 decades, the landmark Centers for Disease Control and Prevention–Kaiser Adverse Childhood Experiences (ACEs) Study1 has contributed to science by providing a persuasive pathogenic model that demonstrates the actual and leading causes of disease and death in the US have their origins early in the life span. Through an investigation of 17,337 US adult health maintenance organization members, the ACE Study found that two-thirds of respondents reported at least one ACE (emotional abuse, physical abuse, sexual abuse; emotional and physical neglect; and residing with a battered mother, household substance abuse, mental illness, parental discord, and criminality). Research from the ACE Study also found a positive dose–response relationship between the total number of ACEs (the ACE score) and multiple health outcomes decades later in adulthood,1 regardless of when individuals were born during the 20th century.2

The convergence of epidemiology with neurobiology and epigenetics3-6 provides substantial knowledge about the underlying biological embedding of childhood trauma, thereby making it a relevant topic of study in medical schools. Efforts to include ACEs science and trauma-informed care (TIC) in health-care delivery is slowly emerging.7,8 However, to date, most efforts to apply ACEs science and the TIC framework8 has taken place in other sectors such as education, child welfare, and criminal justice.9-12 Despite all that is now known about the contribution of ACEs to organic disease, mental illness, risk behaviors, and the associated biological mechanisms, there is little evidence that ACEs science is integrated within formal medical training.

A literature review provided 5 relevant articles pertaining to ACEs and TIC curricula in medical schools.13-18 In these studies of medical schools, a developed curricula for ACEs and TIC were in the early stages, indicating that medical academic institutes still require formalized physician training on these topics early in their education. ACEs and TIC curricula will provide medical students the tools and resources to facilitate patient health and well-being by understanding the root causes of why patients engage in health-risk behaviors. The studies, however, did state that limitations included time constraints to incorporating new curricula. Nonetheless, the studies indicate these new curricula are well received by students and teach them how to acknowledge patients’ ACEs and provide resources for them.

To date, the current medical curriculum lacks ACEs- and TIC-related competency because it has yet to be formally established. The Liaison Committee on Medical Education provides 12 standards called “Structure and Function of a Medical School.” Medical schools must follow these standards to be accredited in the United States and Canada. However, these requirements do not outline standardization for the curriculum to include ACEs- or TIC-related competencies, despite 20 years of research in these areas of study. In addition, there is an overall lack of awareness about ACEs and TIC. Even if information is received, the delivery is not standard across medical schools. Thus, this pilot study aimed to provide the foundation for understanding the current state of ACEs and TIC training at the Medical College of Georgia (MCG). This information can enhance medical student training on these topics by developing a more uniform curriculum, with competencies across medical school programs in the US, and ultimately improve the health outcomes of their future patients.

Current ACEs and TIC Curriculum at MCG

The first introduction to ACEs and TIC offered at MCG was during the fall semester of the 2018–2019 academic year, which corresponds to the first year of the second-year medical student (M2) class. These students were provided a lecture about ACEs and another lecture about TIC principles in the context of performing a physical exam. The first-year medical students (M1s) received a short introduction to ACEs in their fall semester (2019–2020 academic year), and another ACEs lecture in the following spring semester. The third-year medical student (M3) class received no formal introduction to ACEs/TIC during their time at MCG. Since 2016, an elective course called Physicians Power to Protect has been offered in the spring semester of the first-year curriculum. The course teaches M1s how to recognize child abuse and neglect in a clinical setting, using some TIC principles, and the process to follow.

METHODS

Setting and Participants

The study took place during the spring semester of 2020 at MCG. The total number of M1, M2, and M3 students that attended the medical school in academic year 2019–2020 was 568 medical students (192 M1s, 187 M2s, and 189 M3s). The medical school’s institutional review board approved the study.

Our study used a cross-sectional design with a sample of convenience. All M1s, M2s, and M3s were eligible to take part in the study. Fourth-year medical students were excluded from receiving the survey because of a national and state survey they needed to complete that took precedence over others. An online survey was sent to all M1s, M2s, and M3s between April 15 and May 20, 2020. A total of 194 medical students completed the survey (34% response rate); 4 respondents were excluded because of missing information on race/ethnicity. The final sample size for the analysis was N = 190.

The survey included a question on students’ year of medical school. Of the 190 students who completed the survey, 100 indicated they were M1s (52% M1 response rate), 56 were M2s (30% M2 response rate), and 34 were M3s (18% M3 response rate).

Measures on ACEs Training and Knowledge

The survey assessed medical students’ knowledge about ACEs (Table 1). Questions with yes/no responses included 1) Have you ever heard of the ACEs Study? and 2) Have you received information about the ACEs Study? Those students who answered yes question 2 were then asked in what method they received the information (question 3). The following list was provided: lectures given by MCG faculty, guest lectures by others who came to MCG, a state or national conference, specific training attended, my own independent reading, an online video, other resources not listed, and I have not received ACEs information. Question 4 was: Have you seen the ACEs infographic before? Another question was: Do you know when to consider ACEs/trauma in a differential diagnosis for a clinical case? One item also assessed medical students’ perspective about specific ACE exposures among adults in Georgia: Which ACE do you believe has the highest occurrence among adults in the state of Georgia? Students were asked which medical specialty sees the greatest proportion of patients with 1 or more ACE. Medical students were also asked whether they were interested in receiving a problem-based learning (PBL) medical case study that included ACEs/trauma. The available responses were: Very, Somewhat, Neutral, Not really, and Not at all.

Table 1. Training and knowledge about adverse childhood experiences by medical school year

ACEs-related questions Medical college year Total (N = 194) Likelihood ratio/Bonferroni correction  
M1s (n = 101) M2s (n = 58) M3s (n = 35)  
Have you ever heard of the ACEs Study? 93.0%a 80.4% 50.0%a 81.6% Likelihood: p < 0.001  
Bonferroni: p < 0.001  
Yes  
Have you received information/content regarding the ACEs Study? 87.0%a 64.3% 32.4%a 70.5% Likelihood: p < 0.001  
Bonferroni: p < 0.001  
Yes  
If you said yes to the previous question, please indicate how the information was provided:    
1. Lectures given by faculty of the medical school 69.2%a 51.2% 22.7%a 57.7% Likelihood: p = 0.001  
Bonferroni: Faculty  
M1, p = 0.023  
2. Guest lectures by others who came to the medical school 17.6% 23.3% 27.3% 20.5% M3, p = 0.015  
Guest: p > 0.05  
Have you ever seen this infographic before? (See Figure 1 below) 34.0% 28.6% 23.5% 30.4% Likelihood: p = 0.476  
Yes  
Which ACE do you believe has the highest occurrence among adults in the state of Georgia? (Refer to previous image.)    
Physical abuse 8.9% 7.0% 11.4% 8.8%  
Emotional abuse 22.9% 40.4% 34.3% 30.1%  
Sexual abuse 3.0% 10.5% 2.9% 5.2%  
Mental illness 18.8% 7.0% 11.4% 14.0%  
Incarcerated relative 1.0% 0.0% 0.0% 0.5%  
Mother treated violently 0.0% 0.0% 2.9% 0.5%  
Substance abuse 10.9% 10.5% 5.7% 9.8%  
Divorce 34.7% 24.6% 31.4% 31.1%  
Which specialty do you believe will see the highest proportion of patients with 1 or more ACEs?    
1. Internal medicine 3.0% 3.6% 8.% 4.2%  
2. Pediatrics 20.2% 21.4% 32.4% 22.8%  
3. Family medicine 17.2% 17.9% 17.6% 17.5%  
4. Oncology 0.0% 0.0% 0.0% 0.0%  
5. Emergency medicine 19.2% 21.4% 5.9% 17.5%  
6. Surgery 0.0% 0.0% 0.0% 0.0%  
7. Gynecology 0.0% 1.8% 0.0% 0.5%  
8. Psychiatry 21.2% 10.7% 14.7% 16.9%  
9. Dermatology 0.0% 0.0% 0.0% 0.0%  
10. Other 0.0% 0.0% 0.0% 0.0%  
11. All are equal 19.2% 23.2% 20.6% 20.6%  
Do you know when to consider ACEs/trauma in a differential diagnosis for a clinical case? 19.2% 21.4% 38.2% 23.3% Likelihood: p = 0.088  
Yes  
Would you be interested in/wish you had covered a PBL case regarding trauma-informed care/ACEs? Likelihood: p = 0.734  
Very/somewhat 86.9% 82.1% 85.3% 85.2%  

aStatistically significant data determined by Bonferroni correction.

ACEs = adverse childhood experiences; M1 = first-year medical student; M2 = second-year medical student; M3 = third-year medical student; PBL = problem-based learning.

Measures on TIC Training and Knowledge

A separate section included questions on TIC training and knowledge. The first question asked, “Have you ever heard of trauma-informed care?” with responses available as yes or no. The remaining questions asked whether medical students received specific types of training on TIC; their answers were collected using a 4-point Likert scale on agreement: strongly agree, agree, disagree, strongly and disagree, with additional response categories of don’t know and not relevant. Examples included assessing whether students agree with statements such as: I am familiar with principles of TIC. Additional statements included whether the medical curriculum included training on traumatic stress, different cultural issues related to trauma, de-escalation strategies, and how trauma affects a child’s development. Table 2 includes the survey questions.

Table 2. Training and knowledge of trauma-informed care by medical school year

TIC-related questions Medical college year Total (N = 194) Likelihood ratio/Bonferroni correction  
M1s (n = 101) M2s (n = 58) M3s (n = 35)  
Have you ever heard of trauma-informed care? 19.2% 8.9% 17.6% 15.9% Likelihood: p = 0.203  
Yes  
I am familiar with the principles of trauma-informed care. Likelihood: p = 0.123  
Agree 26.0% 12.5% 20.6% 21.1%  
Training at medical school has informed me about the following topics:    
Traumatic stress Likelihood: p = 0.366  
Agree 59.0% 70.4% 64.7% 63.3%  
The human stress response Likelihood: p = 0.345  
Agree 78.0% 85.5% 73.5% 79.4%  
How traumatic stress affects the brain and body Likelihood: p = 0.025  
Agree 67.0% 81.8% 55.9% 69.3%  
Bonferroni: p > 0.05  
The relationship between mental health and trauma Likelihood: p = 0.161  
Agree 63.6% 76.4% 76.5% 69.7%  
The relationship between substance use and trauma Likelihood: p = 0.007  
Agree 57.0%a 74.5% 82.4% 66.7% Bonferroni: p = 0.034  
How trauma affects a child’s development Likelihood: p = 0.022  
Agree 66.0% 85.5% 67.6% 72.0% Bonferroni: p > 0.05  
How trauma affects a child’s attachment to his or her caregivers Likelihood: p = 0.154  
Agree 58.6% 74.1% 64.7% 64.2%  
Different cultural issues (eg, different cultural practices, beliefs, rituals) Likelihood: p = 0.039  
Agree 88.0% 75.9% 94.1% 85.6% Bonferroni: p > 0.05  
Cultural differences in how people understand and respond to trauma Likelihood: p = 0.005  
Agree 39.0%a 63.0% 61.8% 50.0%  
Bonferroni: p = 0.017  
How the trauma and stress of persons with whom we work can affect staff Likelihood: p = 0.005  
Agree 42.0%a 66.0% 64.7% 52.9% Bonferroni: p = 0.017  
How to help patients identify triggers (eg, reminders of dangerous or frightening things that have happened in the past) Likelihood: p = 0.040  
Agree 34.0% 51.9% 52.9% 42.6% Bonferroni: p > 0.05  
How to help patients manage their feelings (eg, helplessness, rage, sadness, terror) Likelihood: p = 0.033  
Agree 37.0% 53.7% 58.8% 45.7% Bonferroni: p > 0.05  
De-escalation strategies (ie, ways to help people to calm down before reaching the point of crisis) Likelihood: p = 0.392  
Agree 35.0% 42.6% 47.1% 39.4%  
How to develop safety and crisis prevention plans Likelihood: p = 0.017  
Agree 22.0% 37.7% 45.5% 30.6% Bonferroni: p > 0.05  
How to establish and maintain healthy, professional boundaries Likelihood: p = 0.450  
Agree 60.6% 68.5% 70.6% 64.7%  

aStatistically significant data determined by Bonferroni correction.

M1 = first-year medical student; M2 = second-year medical student; M3 = third-year medical student.

Data Analysis

A quantitative analysis was performed using IBM SPSS Statistics software (v. 26; IBM, Corp., Armonk, NY) and SAS 9.4 software (SAS Institute, Cary, NC) to calculate frequency and percentage of students who received training and knowledge about specific topics related to ACEs and TIC. For the questions using the Likert scale, answers were categorized in two levels: strongly agree/agree and strongly disagree/disagree/don’t know/not relevant. Likelihood ratio c2 statistics were reported using a p value = 0.05 for statistical significance testing, and Bonferroni corrections were performed on the items with likelihood ratios of p < 0.05.

RESULTS

Out of the 190 students who completed the survey, 100 indicated they were M1s, 56, M2s; and 34, M3s. Within the convenience sample, 13% identified as black or African American; 20%, Asian; 3%, mixed; and 64%, white. Furthermore, 83% of the sample were within the age group of 20 to 25 years; the remaining 17% included students 26 to 30 years old.

Of all the survey items, there were significant differences found among races regarding the following: “Training at medical school has informed me how to help patients identify triggers” (p = 0.048) and “Training at medical school has informed me how trauma affects a child’s attachment to his or her caregivers” (p = 0.038). However, using the Bonferroni correction (p > 0.05), it was determined there were no significant differences among races.

Adverse Childhood Experiences

Overall, 80% of medical students reported hearing about ACEs (93% of M1s, 80% of M2s, and 50% of M3s), with significant differences by medical school year (p < 0.001) (Table 1). Bonferroni correction identified that both the M1s and M3s were responsible for the significant differences (p < 0.001). Receiving information on the ACE Study was reported by 71% of the medical students, with significant differences by medical school year (87% of M1s, 64% of M2s, 32% of M3s; p < 0.001). Bonferroni correction identified that both the M1s and M3s were responsible for the significant differences (p < 0.001). Of the medical students who received ACEs information, 58% reported receiving lectures from faculty of the medical school (69% of M1s, 51% of M2s, and 23% of M3s) and 21% from guest lectures (18% of M1s, 23% of M2s, and 27% of M3s), with significant differences by school year (p < 0.001). After using Bonferroni correction, it was determined there were no significant differences between school years for guest lectures (p > 0.05), but the significant differences remained for lectures from faculty (M1, p = 0.023; M3, p = 0.015). All other questions regarding ACEs science or knowledge showed no statistical significance among M1s, M2s, and M3s.

A total of 30% of students reported seeing the ACEs infographic (Figure 1) (Table 1). When asked about ACE prevalence in Georgia’s general adult population, 31% of medical students responded they believed adults growing up with divorce was the most prevalent ACE, followed by emotional abuse (30%). When asked which specialty would have a high proportion of patients with 1 or more ACEs, 23% reported pediatrics, 18% reported family medicine, 17% indicated psychiatry, and 18% indicated emergency medicine. Knowing how to consider ACEs/trauma in a differential diagnosis for a clinical case was reported by 23% of students. Interest in including ACEs/TIC in a problem-based learning case was reported by 85% of students (Table 1).

tpj20285f1Figure 1. Three types of adverse childhood experiences ACEs. Source: Centers for Disease Control and Prevention. Credit: Robert Wood Johnson Foundation.29

Trauma-informed Care

Agreement on receiving training about different cultural practices, beliefs, and rituals was reported by 76% of M2s compared to 88% of M1s and 94% of M3s (p = 0.039). After using Bonferroni correction, there were no statistically significant differences among groups (p > 0.05). Compared to 63% of M2s and 62% of M3s, only 39% M1s agreed that training at the medical school informed the students about cultural differences in how people understand and respond to trauma (p = 0.005), with M1s responsible for the difference (Bonferroni p = 0.017). Compared to 66% of M2s and 65% of M3s, only 43% of M1s agreed that training informed them of how the trauma and stress of persons which whom they work can affect staff (p = 0.005), with M1s responsible for the difference (Bonferroni p = 0.017).

A total of 67% of students (57% of M1s, 75% of M2s, and 82% of M3s) agreed that training informed them about the relationship between substance use and trauma (p = 0.007), with M1s responsible for the difference (Bonferroni p = 0.034). In addition, 69% of students (67% of M1s, 82% of M2s, and 56% of M3s) agreed that training informed them of how traumatic stress affects the brain and body (p = 0.025); however, a Bonferroni correction determined there were no significant differences among medical school years (p > 0.05).

When asked whether training had informed them of how trauma affects a child’s development, 72% of students agreed (66% of M1s, 86% of M2s, and 68% of M3s), with significant differences among medical school years (p = 0.022). After Bonferroni correction, no significant differences were found (p > 0.05).

Overall, only 43% of students (34% of M1s, 52% of M2s, and 53% of M3s) reported agreement that training had informed them of how to help patients identify triggers, with significant differences found (p = 0.040). However, Bonferroni correction determined no significant differences existed (p > 0.05). Furthermore, only 46% of students (37% of M1s, 54% of M2s, and 59% of M3s) agreed that training had informed them of how to help patients manage their feelings (p = 0.033). After Bonferroni corrections were performed, no significant differences were found among medical school years.

When asked whether training informed them of how to develop safety and crisis prevention plans, only 31% of students (22% of M1s, 38% of M2s, and 46% of M3s) agreed (p = 0.017). However, the Bonferroni correction showed there were no significant differences among medical school years (p > 0.05). No significant differences were found for other statements related to TIC training.

When asked whether they had heard of TIC, 16% of all students answered yes and 21% agreed they were familiar with TIC principles (Table 2). A total of 63% of students (59% of M1s, 70% of M2s, and 65% of M3s) agreed that training at the medical school had informed them of what traumatic stress is, and 79% of students (78% of M1s, 86% of M2s, and 74% of M3s) agreed that training had informed them about the human stress response.

Overall, 70% of students (64% of M1s, 76% of M2s, and 77% of M3s) agreed that training had informed them about the relationship between mental health and trauma. Agreement that training informed them about how trauma affects a child’s attachment to his or her caregivers was reported by 64% of students (Table 2).

For de-escalation strategies (ie, ways to help people to calm down before reaching the point of crisis), 39% of students agreed they received this training. Last, close to two-thirds of the students (65%) agreed that training had informed them of how to establish and maintain healthy professional boundaries.

DISCUSSION

In a nonrepresentative sample of medical school students at MCG, we found that a significant proportion of learners have received ACEs science information. A comparison of M1s and M2s indicated that a large proportion heard of and received information regarding the ACEs Study compared to M3s. Although a large proportion received a lecture through a faculty professor, many reported receiving the training from an external guest lecturer. An ACEs lecture, which introduces ACEs science to the students, was incorporated in the M1 curriculum in academic year 2018–2019—that being the first year of the surveyed M2 students. Without a mandatory ACE lecture in their curriculum, this could explain why a majority of M3s had never heard of the study. In addition, students do not have access to other years’ lectures/materials, so the M3s would not have had access to the ACEs materials given to the M1s and M2s. The Cultural Competency curriculum is required for all medical students; however, formal introduction to ACEs science within the cultural competency curriculum only started with the class of M2s in their first academic year of 2018–2019. Based on our findings, MCG has taken recent measures to ensure that matriculated medical students receive ACEs training.

Across the sampled population, about 1 in 5 students believed that all medical specialties were equal in the proportion of patients that will be seen with one or more ACEs, with pediatrics (22%), family medicine (18%), and psychiatry (17%) being the leading specialties named. These findings are not surprising, given that childhood adversities would affect a pediatric patient population and focus on family dynamics. Moreover, the field of psychiatry/psychology understands the overall impact of trauma on mental health. These answers are apparent to the medical students; however, this illustrates the need to emphasize to medical students that ACEs become embedded biologically and contribute to a wide array of chronic health conditions that require more specialized fields.

MCG implements PBL in the M1 and M2 curriculum. The students are divided into groups of 8 and, facilitated by 2 preceptors, examine a clinical case related to the current module within the curriculum to develop critical thinking skills on how to diagnose and treat a patient. Our findings indicate that more than 80% of students across the 3 medical school years expressed interest in covering a PBL case regarding ACEs/TIC. Our 2 questions showcase both a need and a desire by medical students to be educated further about ACEs and TIC during their first 2 years of the curriculum, before encountering patients in their M3 and fourth-year medical student clerkships.

An important finding from the pilot study is that less than 20% across all 3 medical class years have heard of TIC. The small percentage of students who heard about TIC may be attributed to the students who took an elective course (Physicians Power to Protect), which is only offered in the second semester of the first-year curriculum. The elective is an 8-week course that meets once a week for 1 hour, and is led by an emergency physician and a local child advocacy center (Child Enrichment) that teaches M1s how to recognize and have conversations about nonaccidental trauma in pediatric patients through physical and behavioral assessments. To increase student awareness of TIC, a standardized patient encounter integrating TIC principles can be implemented into the mandatory Physical Diagnosis curriculum, in which students practice how to take patient histories and perform physical exams. A standardized patient encounter in which students must take a history and perform a physical exam using trauma-informed practices and language prepares medical students for what they will see in their clerkships. Importantly, our TIC assessment findings indicate significant gaps in training around cultural differences in responding to trauma; these topics can also be addressed during the Cultural Competency modules. TIC requires acknowledging not only ACEs, but also historical, cultural, and gender identification issues as forms of trauma, and the need for health-care providers to be aware of how certain conditions can affect their patients’ responses.

In recent years, curricula to provide greater awareness about ACEs science and TIC have been observed primarily in sectors such as education, the criminal justice system, allied health, and child welfare. There has been a focus on clients’ experience with trauma, and the vicarious and secondary trauma to members of the workforce who work with traumatized populations. In fact, our findings indicate that medical students, especially the M1s, feel they do not receive training on how trauma can affect their colleagues. Although initial observations about ACEs were made 30 years ago19 in a clinical setting at Kaiser Permanente, the medical community is still in the early phases of awareness, acceptance, and adoption into clinical practice.

After more than 2 decades of ACE Study research along with multiple replications that demonstrate the biological embedding of ACEs, medicine and health-care systems are at a critical juncture to consider adopting the ACEs science formally into medical curricula. Research shows a strong association between childhood trauma and chronic disorders, chronic pain, psychiatric disorders, and medically unexplained diseases. For example, it is proposed that chronic pain develops in those with early childhood adversity as a way to cope and focus attention away from their trauma.20 In addition, those with 3 or more ACEs have an 85% likelihood of an unsuccessful surgical outcome.21 This signifies that the effects of ACEs will be seen in each specialty of medicine, and effectively strengthens the need to include the science of ACEs and TIC principles into medical school curricula.1,21-28 Providing ACEs/TIC in medical curricula will be far more beneficial rather than decades later to practicing health-care professionals, where adoption of ACEs science and TIC poses challenges.

Limitations

There are several limitations in this study that must be noted. First, with the nonrepresentative sample size, we are unable to generalize the findings of this study. In addition, there may have been a response bias involving M1s and M2s as a result of their exposure to ACEs science compared to M3s. Furthermore, we only examined the curriculum at one southeastern medical school. Future studies would be strengthened by including other southeastern medical schools using probability sampling methodology. In addition, gender identity was not obtained in the survey. Nonetheless, the racial/ethnic makeup reflects the overall M1, M2, and M3 population. Although stated in our exclusion criteria, fourth-year medical students were not included in the sample.

CONCLUSION AND FUTURE DIRECTIONS

Despite its limited generalizability, this is the first study with data that begins to understand the knowledge and training gaps related to ACEs science and TIC among medical students across school years. Future studies would benefit from focused evaluations of ACEs and TIC training to include not only the explicit knowledge gained, but also the implicit knowledge of how to apply the science in clinical care. To progress forward, medical practice can benefit from integrating ACEs science into the curriculum, specifically through a standardized patient encounter in a physical diagnosis using TIC practices, and working through a PBL case involving a patient history of trauma. It is important to emphasize within the curriculum that taking patient histories with TIC practices is not a diagnostic tool, but a perspective that acknowledges the barriers for a patient’s optimal health and well-being. For MCG specifically, substantial efforts to learn about ACEs and TIC are driven by student initiative, such as taking the Physicians Power to Protect elective or attending guest lectures, which illuminates further that the future direction of medical training is best informed not only the science, but also by the needs of the students to provide patient-centered care and improve overall health outcomes.

Disclosure Statement

The author(s) have no conflicts of interest to disclose.

Acknowledgments

We thank Dr Richard Cameron and Dr Rebecca Pierce for their support.

Author Affiliations

1Medical College of Georgia, Augusta, GA

2Levine College of Health Sciences, Wingate University, Wingate, NC

Corresponding Author

Jere Tan, BS (jertan@augusta.edu)

Author Contributions

Jere Tan, BS, and Shanta R Dube, PhD, MPH, contributed to the design and implementation of the research, to the analysis of the results, and to the writing of the manuscript.

Financial Support

Jere Tan, BS, was funded in part by the Medical Scholars Program at the Medical College of Georgia in Summer 2020 to carry out and complete this research.

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Keywords: ACEs, adverse childhood experiences, curriculum, medical school, trauma-informed care

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