Uncover trauma to treat patients efficiently

Trauma-informed care incorporates the awareness that trauma has often affected our patients' lives as well as their health. The four R's are often used to describe trauma-informed care: Realize how common trauma is from childhood on in our patients' lives, Recognize the effects of that trauma in their health and in their lives, Respond to that trauma by addressing it in our care for them, and Resist retraumatization. Many times, the processes, the procedures, the things that we routinely do with our patients can retraumatize them and cause undue stress.

Often, when we're taking care of patients, there can be a lot of frustration. Their diabetes is out of control, their hypertension is out of control, they can't quit smoking, they can't quit drinking. We also see patients who are frustrating to our practice in general, including to the front office staff, because they're hard to get along with or don't show up or cancel appointments at the last minute.

Instead of asking the questions, “What is wrong with you? Why are you making our lives here at this clinic so difficult?”, we switch that around and ask the question, “What has happened to you? Let's try to understand the possible origins of the behavior and also the origins of severe uncontrolled disease, because until we understand those, we're not going to be able to help you as fully as we'd like to.”

When I see a patient, especially for the first time, I'll look at their problem list, not so much exactly what the problems are, but how long it is. I'll also look at their medication list, again, looking at how long it is, because sometimes I can predict that something has happened to that person in the past that has caused them to have more problems, tried more medications, and the underlying problem has never been really addressed.

At that point, you may want to start what we call the trauma inquiry. One way that I do it is by looking at the problem they came to me for. If it's chronic back pain, then I might say to them, “Wow, you know, I've seen a lot of my patients who started having pain really early in their lives. Is that something that has happened to you? Tell me about what life was like for you.”

When you ask patients, “How do you think this has affected your life?,” some are going to be very knowledgeable about what's known as ACEs, adverse childhood experiences. There are other people who are going to be totally unaware. That's where we feel the clinician conversation can really be helpful. We have to do it in a way that makes clear that just because you've had these difficult things happen to you in your childhood or your early life, that doesn't mean your life can't get better. It means that we now understand and we need to address things in maybe a little bit of a different way.

The point of these visits is not to unpack the entire conversation. It may be that at one visit, you introduce the topic. You might say something like, “Wow, you've got a lot going on, and we don't seem to be making a lot of progress with some of the problems that you're dealing with. I know that when I've worked with other patients, many times what has gone on in their past, even all the way back to childhood, is affecting their health today. That's something that I would like you to think about, and let's talk about that next time.”

Then, at the next visit, you might ask some further questions and have a discussion about how the neurobiology of trauma, and increased stress hormones, can affect almost every organ system. You can give them something to read about it, or direct them to a reputable website. And then at the next visit, you might bring it up again. Truly understanding these behaviors and their origins makes that relationship a better one, so patients are more open to some of the therapeutic options you might prescribe for them or come up with as a shared decision-making plan.

A lot of our clinicians have concerns about asking these questions because it's opening that can of worms, opening that Pandora's box. But we have found that it does not take as long as people think. We do simulations with our medical students and residents for 15-minute visits. I feel like understanding the origins of some of our patients' behavior and their chronic disease can actually decrease visit time because we know what things might work, and we know that our patients are not going to be able to do some of the things that we ask them to do, so we've stopped being frustrated by that. We feel that it may actually decrease burnout because it helps you truly understand your patient.