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Cutting Close to the Bone: Student Trauma, Free Speech, and Institutional Responsibility in Medical Education

Kumagai, Arno K. MD; Jackson, Brittani MD; Razack, Saleem MD

doi: 10.1097/ACM.0000000000001425

Learning the societal roles and responsibilities of the physician may involve difficult, contentious conversations about topics such as race, gender, sexual orientation, and class, as well as violence, inequities, sexual assault, and child abuse. If not done well, these discussions may be deeply traumatizing to learners for whom these subjects “cut close to the bone.” Equally traumatizing is exposure to injustice and mistreatment, as well as to the sights, sounds, and smells of suffering and pain in the clinical years. This potential for iatrogenic educational trauma remains unaddressed, and medical educators must take responsibility for attending to it. Possible solutions include trigger warnings or statements given to students before an educational activity that may cause personal discomfort. The authors of this Perspective assert, however, both that this concept does not distinguish between psychological trauma and discomfort and that well-intentioned trigger warnings target the wrong goal—the avoidance of distress. Exposure to discomfort not only is unavoidable in the practice of medicine but may be crucial to personal and professional moral development. The authors argue that a more appropriate solution is to create safe spaces for dialogues about difficult topics and jarring experiences. This approach places even the notion of free speech under a critical lens—it is not an end in itself but a means to create a professional ethic dedicated to treating all individuals with excellence and justice. Ultimately, this approach aspires to create an inclusive curriculum sensitive to the realities of teaching and learning in increasingly diverse societies.

A.K. Kumagai is professor and vice chair for education, Department of Medicine, University of Toronto, and F.M. Hill Chair in Humanism Education, Women’s College Hospital, University of Toronto, Toronto, Ontario, Canada.

B. Jackson is a resident physician, Department of Family Medicine, and health disparities scholar, University of Illinois at Chicago College of Medicine, Chicago, Illinois.

S. Razack is associate professor of pediatrics and director, Office of Social Accountability and Community Engagement, McGill University, and practicing pediatric critical care medicine physician, Montreal Children’s Hospital, Montreal, Quebec, Canada.

Editor’s Note: An Invited Commentary by A. Bleakley appears on pages 289–291.

Funding/Support: Arno K. Kumagai is supported by an endowment from the F.M. Hill Foundation of Women’s College Hospital, University of Toronto.

Other disclosures: None reported.

Ethical approval: Reported as not applicable.

Correspondence should be addressed to Arno K. Kumagai, University of Toronto, Women’s College Hospital, 76 Grenville St., Toronto, ON M5S 1B2, Canada; telephone: (734) 615-4886; e-mail:

© 2017 by the Association of American Medical Colleges