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What if we treated every patient as though they had lived through a trauma?

Julia Haskins , Special to AAMCNews
May 24, 2019

That’s not far off the mark, as more than 50% of the U.S. population has experienced a traumatic event. Here’s how some medical schools and teaching hospitals are using trauma-informed care to help all patients.

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The man in the clinic exam room looked crestfallen: he had experienced homelessness and struggled with schizophrenia and other chronic health issues throughout his life, recalls Sadie Elisseou, MD. Elisseou could have completed the man’s exam without taking his sensitive history into account. Instead, she used a trauma-informed approach, explaining every step of the exam process and moving slowly throughout. In response, her patient felt comfortable enough to share the emotional pain he’d endured.

“Trauma-informed care is putting the patient in control of their environment, their body, their experience, for people like this gentleman who perhaps haven't been made to feel in control very much at all,” says Elisseou, a primary care physician in the Veterans Health Administration system.

In fact, Elisseou and other providers of trauma-informed care (TIC) assume that every patient may enter a health care setting having experienced some form of trauma. That’s not so far off the mark: more than half of the U.S. population reports experiencing at least one traumatic event in their lives.

Often, trauma stems from sexual violence. The Centers for Disease Control and Prevention reports that more than one-third of women and nearly one-quarter of men have experienced sexual violence. But trauma has many possible causes, including surviving a natural disaster, witnessing violence, and facing poverty or bigotry. And early traumas — adverse childhood experiences (ACEs) such as neglect — can be particularly damaging.

“Without [trauma-informed care], providers risk retraumatizing patients, making them feel vulnerable in a place where they should feel comfortable getting the care they need.”

Malika Fair, MD, MPH
AAMC

Whatever the causes, trauma can lead to serious health problems, including depression, cardiovascular disease, diabetes, and substance use disorders. And those who have experienced trauma may be reluctant to seek health care, in part because of its intimate nature.

In the wake of the #MeToo movement and other social justice campaigns, the use of TIC is growing. From asking personal questions in a sensitive manner to making sure to consider a patient’s whole history, teaching hospitals and medical schools are incorporating tenets of the approach into many forms of care.

“Increasingly, institutions are recognizing that trauma-informed care is essential to providing quality care,” notes Malika Fair, MD, MPH, a practicing emergency physician and the AAMC’s senior director of health equity. “Without it, providers risk retraumatizing patients, making them feel vulnerable in a place where they should feel comfortable getting the care they need.”

Empowering the patient

Patients who have lived through trauma often feel that their power has been stripped of them in some way and are at risk of reexperiencing feelings of fear and vulnerability. Health care environments can trigger those feelings because they involve intimate interactions, invasive procedures, and unequal power dynamics.

“It’s really all about trying to give each patient as much autonomy and control over their situation as possible.”

Melinda Manning, JD
University of North Carolina Hospitals

In response to such realities, many of the Substance Abuse and Mental Health Services Administration’s (SAMHSA) guiding principles for trauma-informed care center on making patients feel safe and empowered. Providers of TIC weave these principles throughout their patient interactions.

A provider implementing TIC might ask whether a patient prefers the door open or for permission to remove a paper gown. A provider also might explain the need to ask a personal question or to touch an intimate part of the body.

At the University of North Carolina (UNC) Hospitals’ Beacon Program, staff use a trauma-informed approach when caring for patients experiencing interpersonal abuse. Program director Melinda Manning, JD, MSW, says providers give patients choices that affirm their input at every step.

“It’s really all about trying to give each patient as much autonomy and control over their situation as possible,” says Manning. Sometimes, she notes, patients aren’t ready to communicate or want to terminate the visit, which is completely within their rights.

In fact, argue TIC advocates, letting patients lead aligns with the well-recognized value of patient-centered care. “A misconception is that trauma-informed care is something completely new and different,” says Elisseou. Rather, she notes, the practice relies on basic tenets of good care, like respect, professionalism, and communication.

Opening up communication

Building strong patient-physician communication is central to providing TIC, say experts.

“Sometimes this is the first time the patient really has the opportunity to talk about what’s happened to them,” says Manning. “And if they open up about this, they open up about other parts of their life as well,” which can improve the quality of the care they receive.

Whether or not a patient chooses to disclose trauma, it’s important to approach all patients as though they may have lived through something painful, she says. “Those experiences affect how [patients] access health care and how they receive health care. And [providers] need to be aware of that.”

“As a program rooted in health equity, PRIME-US helps students develop an understanding of how trauma across the individual, family, community, and societal levels affects health.”

Leigh Kimberg, MD
University of California, San Francisco School of Medicine

Rooting communications in TIC may involve choosing one’s words carefully — such as saying “examination table” rather than “bed” to avoid an association with sex. It also involves respecting a patient’s privacy, asking only for necessary personal details when taking a history. And it means showing a focus on the patient, such as making good eye contact.

“You need to engage in a conversation with a patient that opens up a dialogue as opposed to checking off a box,” says Annie Lewis-O’Connor, PhD, MPH, who founded and directs the Coordinated Approach to Resilience and Empowerment Clinic for survivors of domestic and sexual violence and human trafficking at Brigham and Women’s Hospital in Boston, Massachusetts.

“Patients with trauma and abuse histories don’t do well in a harried environment,” and may be hesitant to talk to providers who appear rushed, says Lewis-O’Connor. To properly carry out TIC, providers need to slow down and make sure they are fully grasping their patients’ needs.

Providers also need to realize that certain sights, smells, or sounds in a medical environment can trigger painful associations for patients who have experienced trauma, says Leigh Kimberg, MD, professor of medicine at the University of California, San Francisco (UCSF), School of Medicine. That means providers should look for nonverbal cues, such as more rapid breathing, that can signal emotional distress.

“It’s really about paying attention to the patient’s response and asking them, ‘What would make this visit feel healing for you? What would help you feel like this is a place that you could come back to?’” says Kimberg.

Considering the whole patient

When helping patients, TIC providers look at the bigger picture: What traumatic forces have shaped a patient’s life and health?

Acknowledging these factors is core to the Women’s HIV Program (WHP) at UCSF.

“While medicine has made great strides in treating the HIV virus with medications, it has lagged in treating the other co-occurring medical and psychosocial conditions that are leading to high rates of preventable illness and death,” says Edward Machtinger, MD, WHP director.

Machtinger analyzed data on WHP patients’ mortality and found that most were dying not from HIV, but from violence, suicide, addiction, and diseases associated with lifelong trauma. Then came the tragic murder of a patient, which underscored the need to recognize the social, cultural, and community factors beyond medicine that affect patients’ lives.

“We realized that this huge missing ingredient in our care model was understanding the impact of cumulative trauma on their lives, and really understanding how to help people cope with this experience of cumulative trauma in ways that are [healthier] for them,” Machtinger notes.

Cultural and historical trauma, from xenophobia to racism to transphobia, all affect patients’ health, she says, and simply acknowledging that patients have been through these hardships can help them feel understood. Once that understanding has been established, providers can then determine the best course of care. Sometimes, that involves referring patients to outside programming or resources, such as peer support groups that connect them with others who have experienced trauma.

In New York, Montefiore Medical Group has implemented a system-wide TIC pilot program for physicians, administrators, nurses, and social workers that incorporates an awareness of social factors and cultural biases.

In leading curriculum development for the pilot, Dana Crawford, PhD, director of Montefiore’s Trauma-Informed Care Program, included training on the role of social determinants of health to help providers better understand how race, culture, and prejudice can fuel trauma. She also implemented training to reduce unconscious cultural bias, in which staff learn how their own prejudices may affect how they provide care.

“All parts of you matter. Your past and your future and your current experiences are all connected.”

Dana Crawford, PhD
Montefiore Medical Group

These discussions are also intertwined with Montefiore’s universal screening for adverse childhood experiences (ACEs). All patients — and parents of pediatric patients — are encouraged to complete an ACEs survey to give providers insight into the stressors affecting their health and wellness. Medical residents shadow psychologists to learn how to ask patients about ACEs.

“Part of the role of our psychologists and our behavioral health team is to say, ‘All parts of you matter,’” says Crawford. “Your past and your future and your current experiences are all connected.”

Teaching the next generation

Proponents of TIC are excited to see future physicians increasingly embrace TIC as the norm in medicine. “The students of this generation are already so primed and ready for TIC,” says Elisseou. "Young physicians nowadays are called to address social illness, so to speak, in addition to individual illness.”

Students in the Program in Medical Education for the Urban Underserved (PRIME-US) explore health equity issues by learning directly from community members in local under-resourced communities. Kimberg is the program director for PRIME-US, a five-year supplementary curricular program, which is open to students at the UCSF School of Medicine and the University of California, Berkeley-UCSF Joint Medical Program.

“We use an anti-oppression framework to explore power and control in society and analyze how these forces impact health,” says Kimberg.

Elisseou has also been working to advance TIC in medical education. She was the course leader for the doctoring skills clinical course at the Warren Alpert School of Medicine at Brown University, where she says students came to her asking for TIC instruction.

In January 2019, MedEdPORTAL® published a curriculum Elisseou and co-authors created on teaching first-year medical students how to perform a trauma-informed physical exam. Following the curriculum, students’ familiarity with, confidence in, and usage frequency of TIC increased, the researchers report. And, Elisseou says, medical schools can expect more students to start asking for TIC education.

“Much of medical school curricula are driven by need,” she says. “What are medical students saying that they need? What is going on in society and in the news that will affect the practice of medicine? And I think that TIC is that next thing.”

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