#218 Trauma-Informed Care with Megan Gerber MD

June 8, 2020 | By Beth Garbitelli

Tips for a trauma-informed medical history, physical exam and practice setting aka Universal Trauma Precautions

Join us as we delve into the paradigm-shifting ethos of trauma-informed care with renowned expert Dr. Megan Gerber. Dr. Gerber is an Associate Professor of Medicine at Boston University School of Medicine and serves as Medical Director of Women’s Health for VA Boston where she directs the Women’s Health Fellowship. Dr. Gerber edited the textbook, “Trauma-informed Health Care Approaches: A Guide for Primary Care.”  We discuss the framework for trauma-informed universal precautions, as well as basics about the prevalence of trauma, strategies for integrating a trauma-sensitive approach into primary care, practical changes for the office environment,  modifications for physical exam methods, and more.

We recognize this topic may bring up upsetting thoughts or memories for some of our listeners. We will provide some self-care and trauma-informed resources in our show notes. The practice of medicine, especially during times of national crisis, can increase our exposure to traumatic events and reactivate difficult memories, predisoposing folks to depression and suicide risk. We just want to reiterate that you are not alone. If you are struggling with thoughts of harming yourself, the national suicide prevention lifeline number is 1-800-273-8255.

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Credits

Producer/Writer/Graphics: Beth Garbitelli

Co-Producer: Paul Williams MD

Hosts: Matthew Watto MD, FACP; Paul Williams MD, FACP, Beth Garbitelli 

Editor: Molly Heublein MD (written materials); Clair Morgan of nodderly.com

Guest: Megan Gerber MD, MPH, FACP

Sponsor

Join the American College of Physicians today! Post-training physicians can take advantage of an exclusive limited-time $100 dues discount. Visit acponline.org/member and use the code ACPDISCOUNT. Discount is only available until June 30, 2020.  

We are excited to announce that the Curbsiders are now partnering with VCU Health Continuing Education to offer continuing education credits for physicians and other healthcare professionals. Check out curbsiders.vcuhealth.org for more information.

Time Stamps

• Intro, disclaimer, guest bio (0:00 – 4:09)
• Guest one-liner (4:24)
• Picks of the Week*: Keep Going: 10 Ways to Stay Creative in Good Times and Bad by Austin Kleon; Pilgrim at Tinker Creek by Annie Dillard; Molly’s Challah on King Arthur Flour website from cook/food writer Molly Yeh; OXO Good Grips Stainless Steel Food Scale with Pull-Out Display; Buffy the Vampire Slayer on Hulu, Amazon Prime; Devs on Hulu, Amazon Prime; Terry Pratchett’s Discworld series (Book 1 of 40: The Color of Magic, Night Watch) and The Wee Free Men; On Becoming a Healer by Saul J. Weiner MD (10:16) 
• Kashlak Cases (14:39)
• Epidemiology of trauma (16:11)
• Trauma and #MeToo (19:04)
• Defining Trauma-Informed Care (TIC) (19:56)
• Integrating TIC into primary care (23:42)
• Screening in TIC (25:56)
• Containment and retraumatization (29:56)
• Inquiring about trauma (31:39)
• Recap and Office Visit Mechanics (36:24)
• Building the Relationship (38:56)
• Common Inquiry Mishaps (39:46)
• TIC Physical Exam (41:14)
• Resources for Patients (45:24)
• Office Environment (48:56)
• Provider Burnout (50:56)
• TIC in Covid-19 (53:24)
• Take-home Points (57:14)
• Outro (65:44)

Trauma-Informed Care Pearls

1. Never exclude trauma from your differential. 
2. In addition to personal trauma, people may come from a community that experiences discrimination, racism, or other forms of structural and historical violence. 
3. We should be less afraid to inquire about trauma. It is not necessary to elicit a highly-detailed trauma history from a patient. 
4. Dr. Gerber recommends asking open-ended questions to begin a discussion.  Some options to consider include the stem from the PC-PTSD-5 (“Sometimes things happen to people that are unusually or especially frightening, horrible, or traumatic. For example: a serious accident or fire, a physical or sexual assault or abuse, an earthquake or flood, a war, seeing someone be killed or seriously injure,  having a loved one die through homicide or suicide. Have you ever experienced this kind of event?”) or an even more open-ended question like:  “Have you experienced anything that makes seeing a doctor difficult or scary for you?” (Millstein, 2020).
5. Avoid any personalizing language in the entire physical exam (Ex: “In order to evaluate your sore throat, I will need to look in the back of the mouth, is that okay?” instead of saying “ Open your mouth for me”) 
6. Ask patients what may make the exam more comfortable for them (Ex: Allowing patients the opportunity to listen to music) and ask them to disrobe to their level of comfort.

Infographic 1  by Beth Garbitelli

Infographic 2 by Beth Garbitelli

Infographic 3 by Beth Garbitelli

Trauma-Informed Care Notes

Trauma and Health Impacts

Trauma “results from an event, series of events, or set of circumstances experienced by an individual as physically or emotionally harmful or life-threatening with lasting adverse effects on the individual’s functioning and mental, physical, social, emotional, or spiritual well-being” (Substance Abuse and Mental Health Services Administration, SAMHSA). Anyone can experience trauma.  Trauma includes sexual abuse, intimate partner violence, elder abuse, combat trauma, and more (Raja, 2015). 

Trauma is incredibly prevalent.  National surveys indicate the rate of child mistreatment is 25.6% and the rate of sexual assault in childhood is 4.2%  (Gerber et al, 2019).  The CDC’s National Intimate Partner and Sexual Violence Survey found that one in three women (35.6%) and one in four men (28.5%) have experienced rape, intimate physical violence, or stalking in their lifetime. 

One of the groundbreaking studies in the realm of trauma found that patients reporting higher numbers of adverse childhood experiences (ACEs) were at increased risk for smoking, severe obesity,  sexually transmitted infections, and suicide attempts (Felitti et al, 1998). Researchers also found a dose-response relationship between ACEs and heart disease, cancer, chronic bronchitis, liver disease and more (Felitti et al, 1998). This initial study population was all insured, mostly white, and mostly middle-class. A recent survey of over 214,000 people across 23 states found approximately 61.55 % of respondents reported at least one ACE in their lifetime (Merrick, 2018).

Trauma causes direct physiologic changes with adverse health impacts, including activation of the hypothalamic-pituitary-adrenal (HPA) axis and stress hormones, which may play a role in chronic inflammation and disease development  (Gerber et al, 2019).

Trauma-informed care (TIC) is a strengths-based care delivery approach that fosters recovery and healing through safe and collaborative relationships. TIC functions as a form of universal precautions. Trauma survivors have had their trust violated, especially in health care situations so the goal is to avoid inadvertently retraumatizing patients while fostering collaborative and trusting care (Gerber et al, 2019). 

The Six Core Components in the SAMHSA structure of a Trauma-Informed Approach include safety, trustworthiness and transparency, peer support, collaboration and mutuality, empowerment, voice and choice and sensitivity to cultural, historical, and gender issues (SAMHSA, 2014). Providers may embody these principles by creating a safe office environment for disclosures, communicating in a direct manner with patients, assisting patients in finding peer resources, offering choice in care options and delivery, and respecting the personal and cultural heritage of a patient. 

In addition to personal trauma, people may come from a community that experiences discrimination, racism, or other forms of structural and historical violence. Trauma-informed care calls on providers to be aware that communities bear collective trauma which can make medical interactions challenging.

Integrating Trauma-Informed Care into Practice

Even a young, healthy person may have experienced trauma. In an initial visit, Dr. Gerber suggests getting to know the patient and taking a strong social history, without necessarily assessing specific traumas. However, it is important to not exclude trauma from your differential for any patient.

Screening

As in all care, evidence-based screening is the most efficacious and useful.  For example, the U.S. Preventive Services Task Force (USPSTF) recommends screening women of reproductive age for intimate partner violence (IPV)  but does not recommend screening for adverse childhood experiences (ACEs) or sexual assault.

You can practice a trauma-sensitive approach without knowing any details about a person’s trauma history. Not every system is ready to screen or has something to offer to patients who are screened, so Dr. Gerber recommends a case-finding approach that involves asking open-ended questions about trauma, screening for specific types of trauma,  conducting universal education in the practice,  and developing an environment with patient cues (such as pamphlets and posters) that indicate the office is safe space for trauma discussions. 

Containment 

Core components in some understandings of TIC include the 4 Cs: Care, Calm, Contain, Cope (Kimberg, 2016). Containment in TIC can refer to the notion of allowing a patient to feel safe and respecting their timeline for disclosing a trauma. Some evidence shows that survivors want to be asked about their trauma histories (Goldstein, 2017)  But it is not necessary to elicit a highly-detailed trauma history from a patient. Patients want to talk about trauma when they are ready, per Dr. Gerber.

How to Ask

In Dr. Gerber’s expert opinion, we are much more likely to re-traumatize patients inadvertently through office environment or exam procedures than history taking, and we should be less afraid about inquiring about trauma.

There are many forms of trauma that we don’t have specific screening tools for such as racism, community violence, and human trafficking.  Because of the broad and diverse nature of trauma exposures, Dr. Gerber recommends asking broad questions to begin a discussion.  Some options to consider include the stem/intro question to the  PC-PTSD-5 (full stem below) or an even more open-ended question like:  “Have you experienced anything that makes seeing a doctor difficult or scary for you?” (Millstein, 2020).

Focusing on the Relationship

Trauma-informed care is patient-centered care. Even though many physicians practice these methods everyday, it is important to remain humble and mindful of these principles. In medicine, we are wired to take detailed histories and nail a diagnosis, but the patient may not always be ready to talk about their past.

Issues arise when providers do not develop a sense of safety for the patient, according to Dr. Gerber.  For example, if someone seems agitated or anxious, that may not be the time to ask about a trauma history. Reading a question in  a very wooden way from an electronic health record prompt and looking at the computer or typing when someone discloses can be off-putting to the patient, per Dr. Gerber. Other history-taking pitfalls to avoid are repetitive requests for information or requesting explicit, unnecessary details of a trauma history for purposes of documentation, according to Dr. Gerber. 

Building a Trauma-Informed Physical Exam

Some exams such as the breast, pelvic, and prostate exams can be challenging for trauma survivors but we also make assumptions about which parts of the body may have experienced trauma and we can be wrong. Dr. Gerber recommends avoiding any personalizing language in the entire physical exam (Ex: “In order to evaluate your sore throat, I will need to look in the back of the mouth, is that okay?” instead of saying “Open your mouth for me”) 

Obtain consent for each part of the exam and be sure that the patient knows when and why you’re doing something (Elisseou, 2018). Dr. Gerber recommends keeping a running narrative dialogue with the patient throughout the exam. Dr. Gerber also recommends asking a patient to disrobe to their level of comfort as well as asking patients what may make the exam more comfortable for them (Ex: Allowing patients the opportunity to listen to music).

Dr. Elisseou developed a curriculum module for medical students which may be adapted for other medical professionals, office staff,  and trainees on the topic of trauma-informed physical examination practices. 

Navigating Resources After Disclosure 

After a disclosure of trauma, you should share an empathic and validating response.  Components of an effective response to trauma disclosure involve accepting and verbally acknowledging the disclosure, expressing empathy, clarifying confidentiality, normalizing the experience by expressing prevalence of abuse, validation, addressing any time limitations, offering reassurance,  and collaborating with the patient on an immediate self care plan (Schachter, 2008) It is also recommended to ask if this is the first disclosure and to inquire about social and therapeutic support (Schachter, 2008). 

Dr. Gerber recommends to first assess safety after the disclosure of an acute trauma. The next step is to determine how much difficulty this trauma is causing in their life (Ex: relationship difficulties, nightmares, trouble leaving house, etc.) For specific types of trauma, especially if they are in immediate danger,  hotline numbers on palm cards can be helpful to have available. Social work and therapy referrals are important if possible. 

Dr Gerber notes that sometimes a patient may disclose a trauma and “it may end there”. They may not want or need anything other than to be heard and your support/validation.

Developing a Safer Office

Tips for developing a more peaceful, less triggering office environment involve rearranging the waiting room chairs to allow more personal space and reducing ambient noise, especially  preventing door slams (Ex: with door stoppers, padding, etc).

Helping  Providers

It is important to remain mindful of compassion fatigue and vicarious traumatization which may occur when dealing with a high volume of patients with trauma history.  One strategy is calming and grounding yourself before a visit, taking a deep breath and focusing on what may be at the root of a patient’s presentation, according to Dr. Gerber. 

Trauma-Informed Care in the Age of Covid-19

Pandemics can unleash lasting mental health challenges, including depression, anxiety, post-traumatic stress, substance use disorder (SUD) in survivors. In the SARS outbreak of the early 2000s, researchers found increased rates of depression and PTSD in survivors (Mak, 2009) and there is some evidence that health care workers who dealt with SARS were susceptible to chronic mental health outcomes (Lee, 2007) (Maunder, 2006)(Lancee, 2008) (Galea, 2020)

Gerber advises that there may be a second wave of mental health and substance use challenges from the pandemic and the era of social distancing for providers to be aware of for their patients and their peers going forward.  Dr. Gerber talks more about trauma-informed telehealth on the Women Centered Health podcast.

Links*

1. Keep Going: 10 Ways to Stay Creative in Good Times and Bad by Austin Kleon
2. Pilgrim at Tinker Creek by Annie Dillard 
3. Molly’s Challah on King Arthur Flour website from cook/food writer Molly Yeh
4. OXO Good Grips Stainless Steel Food Scale with Pull-Out Display
5. Buffy the Vampire Slayer on Hulu, Amazon Prime
6. Devs on Hulu, Amazon Prime
7. Terry Pratchett’s Discworld series (Book 1 of 40: The Color of Magic, Night Watch) and The Wee Free Men
8. On Becoming a Healer by Saul J. Weiner MD

*The Curbsiders participates in the Amazon Services LLC Associates Program, an affiliate advertising program designed to provide a means for sites to earn advertising commissions by linking to Amazon. Simply put, if you click on our Amazon.com links and buy something we earn a (very) small commission, yet you don’t pay any extra.

Goal

Listeners will gain fluency in trauma-informed care practices, methods, and perspectives in order to deliver compassionate care to patients who have experienced trauma and reduce the impacts of trauma in the healthcare setting. 

Learning objectives

After listening to this episode listeners will…  

1. Define trauma-informed care and discuss the various forms of trauma. 
2. Develop increased awareness of prevalence of adverse childhood experience, post-traumatic stress disorders, sexual violence, and intimate partner violence.
3. Foster a safe, calm, welcoming clinical environment for patients who have experienced trauma. 
4. Manage trauma disclosures and assess appropriate next steps for care and referrals.
5. Cultivate advanced communication skills and strategies on the topics of sexual violence, intimate partner violence, and other trauma-related experiences. 
6. Be able to engage in harm reduction strategies when caring for patients with trauma history. 

Disclosures

Dr. Gerber reports no relevant financial disclosures. The Curbsiders report no relevant financial disclosures. 

Citation

Garbitelli EC, Gerber MR, Williams PN, Heublein M, Watto MF. “#218 Trauma-Informed Care with Megan Gerber MD”. The Curbsiders Internal Medicine Podcast. http://thecurbsiders.com/episode-list June 8, 2020.

Resources

• ACP’s Individual Physician Well-being and Burnout Tools
• AAFP’s Physician Health First 
• Cambridge Health Alliance Daily Free Live-Online Community Practice
• Physician Support Line –  1 (888) 409-0141
• Headspace for Healthcare Professionals (AMA members may receive free Headspace as well)
• National Suicide Prevention Lifeline – 1-800-273-8255 
• The Nocturnists podcast
• MGH Guide to COVID-19 Mental Health Resources – Health Care Providers  (more MGH resources here, including some on mindfulness and physical activity) 
• Provider tool kit from National Center for PTSD (NCPTSD) 

References

1. Gerber, M. Trauma-informed Health Care Approaches: A Guide for Primary Care.  Springer. 2019. 
2. SAMHSA Trauma-Informed Resources [https://www.integration.samhsa.gov/clinical-practice/trauma-informed] 
3. Felitti V, et al.  Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study.  Am J Prev Med. 1998 [https://www.ncbi.nlm.nih.gov/pubmed/9635069]
4. Merrick M, et al. Prevalence of Adverse Childhood Experiences From the 2011-2014 Behavioral Risk Factor Surveillance System in 23 States. JAMA Pediatr. 2018. [https://pubmed.ncbi.nlm.nih.gov/30242348/]
5. The National Intimate Partner and Sexual Violence Survey: 2010 Summary Report [https://www.cdc.gov/violenceprevention/pdf/nisvs_executive_summary-a.pdf]
6. SAMHSA’s Concept of Trauma and Guidance for a Trauma-Informed Approach prepared by SAMHSA’s Trauma and Justice Strategic Initiative. 2014. [https://ncsacw.samhsa.gov/userfiles/files/SAMHSA_Trauma.pdf]
7. Raja, S et al. Trauma informed care in medicine: current knowledge and future research directions. Fam Community Health. 2015 [https://www.ncbi.nlm.nih.gov/pubmed/26017000]
8. Gerber, M, Block, Bradley. Physician’s Guide to Trauma-Informed Healthcare Approaches with Dr. Megan Gerber. Physician’s Guide to Doctoring. [https://physiciansguidetodoctoring.libsyn.com/physicians-guide-to-trauma-informed-care-with-dr-megan-gerber]
9. Millstein, J. Becoming Trauma Informed. J Gen Intern Med. 2020 [https://www.ncbi.nlm.nih.gov/pubmed/32318901]
10. Kimberg, L., Trauma and Trauma-Informed Care, in The Medical Management of Vulnerable and Underserved Patients: Principles, Practice and Populations. Talmadge King and Margaret Wheeler, Editors. 2016, McGraw-Hill Companies
11. The Primary Care PTSD Screen for DSM-5 (PC-PTSD-5) – Screening Tool [https://www.ptsd.va.gov/professional/assessment/documents/pc-ptsd5-screen.pdf]
12. SAMHSA Screening Tools
13. Elisseou, S. Creating Safe, Healing Relationships and Environments – Trauma-Informed Physical Exam: Practicing Sensitivity. SAMHSA-HRSA Center for Integrated Health Solutions National Council for Behavioral Health. 2018. [https://integration.samhsa.gov/about-us/innovation-communities-2018/05.23.18_May_Webinar_TIC.pdf]
14. Schachter, C et al.  Handbook on Sensitive Practice for Health Care Practitioners: Lessons from Adult Survivors of Childhood Sexual Abuse. Ottawa: Public Health Agency of Canada. 2008. [https://www.integration.samhsa.gov/clinical-practice/handbook-sensitivve-practices4healthcare.pdf]
15. Pearlman, L &  McKay, L. Understanding & Addressing Vicarious Trauma. Headington Institute [https://headington-institute.org/files/vtmoduletemplate2_ready_v2_85791.pdf]
16. Mak I, et al. Long-term psychiatric morbidities among SARS survivors. Gen Hosp Psychiatry. 200. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7112501/]
17. Lee A et al.  Stress and Psychological Distress Among SARS Survivors 1 Year After the Outbreak. Can J Psychiatry. 2007  [https://www.ncbi.nlm.nih.gov/pubmed/17500304]
18. Maunder R et al. Long-term psychological and occupational effects of providing hospital healthcare during SARS outbreak. Emerg Infect Dis. 2006. [https://www.ncbi.nlm.nih.gov/pubmed/17326946]
19. Lancee W et al. The prevalence of mental disorders in Toronto hospital workers one to two years after SARS. Psychiatr Serv. 2008 [https://www.ncbi.nlm.nih.gov/pubmed/18182545]
20. Galea S, et al. The Mental Health Consequences of COVID-19 and Physical Distancing: The Need for Prevention and Early Intervention.  JAMA Intern Med. 2020. [https://pubmed.ncbi.nlm.nih.gov/32275292]
21.  Rittenberg, M and Lewis-O’Connor A.  What is trauma-informed care? American Hospital Association presentation. 2019. [https://www.aha.org/system/files/media/file/2019/07/what-is-trauma-informed-care-6-11-2019-.pdf]
22. Elisseou S.  A Novel, Trauma-Informed Physical Examination Curriculum for First-Year Medical Students. MedEd Portal. 2019. [https://www.mededportal.org/doi/10.15766/mep_2374-8265.10799]
23. Kuehn, B. Trauma-Informed Care May Ease Patient Fear, Clinician Burnout. JAMA. 2020 [https://www.ncbi.nlm.nih.gov/pubmed/31995128]
24. Novick, D. Sit Back and Listen — The Relevance of Patients’ Stories to Trauma-Informed Care. NEJM. 2018 [https://www.nejm.org/doi/full/10.1056/NEJMp1809633]
25. The Women Centered Health Podcast. EP 35: Trauma Informed Telehealth with Dr. Megan Gerber [http://womancenteredhealth.com/telehealth/]
26. Machtinger EL, et al. From Treatment to Healing: Inquiry and Response to Recent and Past Trauma in Adult Health Care. Women’s Health Issues. 2019. [https://pubmed.ncbi.nlm.nih.gov/30606467/]