A magazine for friends of the Warren Alpert Medical School of Brown University.

Protecting Patients

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The Warren Alpert Medical School leads the country in training students to provide trauma-informed care.

Sadie Elisseou ’06 MD’10 calls her next patient’s name into the primary care waiting room on the first floor at the Providence VA Medical Center on a cold, clear morning last December. As he approaches, she greets him with a broad smile and a warm “Good morning! So great to see you.”

The patient is a burly, broad-shouldered, middle-aged man who served in Korea, Afghanistan, and Iraq and has diagnoses of depression, anxiety, a traumatic brain injury, alcohol use disorder, and symptoms of post-traumatic stress disorder. For the next 40 minutes, Elisseou, an internist at the VA and assistant professor of medicine at the Warren Alpert Medical School, takes the patient’s history, gives him a high five to congratulate his sobriety, performs a physical exam to identify the source of the persistent pain in his lower back, and works with him to develop a treatment plan that takes into account his wariness of medications and the changes in VA coverage for a massage therapist he’s found particularly effective.

Elisseou asks each question, performs each maneuver, and gives each directive with professional precision and compassion. As she explains later, she considers every aspect of the encounter an opportunity to maximize her patient’s feeling of autonomy and safety. “I am going to reach behind you to get the otoscope,” she says, while maintaining a firm hand on his shoulder to establish her presence. After discussing his options for medication, massage therapy, and yoga, Elisseou walks him to the checkout desk, thanks him, and wishes him happy holidays.

Her carefully executed patient interactions fit into a named set of practices that are gaining recognition in the medical community. In September 2017, Elisseou introduced the trauma-informed physical exam framework, upon which these exam maneuvers are based, to the MD Class of 2021. She says there have been no published reports of curricular incorporation of trauma-informed practices at other medical schools—meaning the Warren Alpert Medical School may be the first in the country to include them in an undergraduate medical curriculum.

Family Values

The concept of trauma-informed practice emerged in the late 1980s and early 1990s as providers began to observe the association between mental illness and previous trauma, particularly among women receiving public mental health services. At the same time, researchers were beginning to understand the biological effects of trauma and stress. Trauma-informed practices initially gained traction in the fields of education, psychology, and behavioral health, but the concept is now taking hold in the broader medical community. Both the National Council for Behavioral Health and the Substance Abuse and Mental Health Services Administration (SAMHSA) have invested significant resources in trauma-informed care programs, and the Centers for Disease Control and Prevention addresses trauma and trauma-related care on its website. The National Council consults with health care organizations around the country to help improve trauma-informed practices, by ensuring that all staff can screen for and identify trauma in a patient’s history, understand and respond to trauma, and avoid re-traumatization. SAMHSA refers to this paradigm as the four Rs: realization, recognition, response, and resistance to re-traumatization.

Elisseou didn’t know all of this when she began incorporating trauma-informed care into her practice. Maybe it came naturally to her; her father has an internal medicine practice in Connecticut, and her mother manages the office. She says her parents taught her and her brother and sister the importance of love and affection for one another and for others, making them kiss each other good night—“something which we despised at the time, but are now grateful for it, since we’re best friends,” she says—and to greet adults “with eye contact and a firm handshake.” As an undergrad and then a medical student in Brown’s Program in Liberal Medical Education, Elisseou began to see how she could apply these values of kindness and communication in her interactions with patients. “I made it a priority to do everything I could to make my patients feel as comfortable as possible in the interview and, particularly, during the physical exam,” she says.

As Elisseou gained appreciation for the patient interaction and information-gathering components of the physical exam during her internal medicine residency at Yale, so did her understanding of the hazards it posed to people who had previously experienced trauma. “It has the potential to expose patients to shame and vulnerability and triggers of previous trauma,” she says. Now, working with veterans, she sees patients daily who have experienced combat-related trauma, military sexual trauma, homelessness, adverse childhood experiences, and other challenging backgrounds. She recalls performing a cardiac exam on one of her first patients at the Providence VA: “I brought my stethoscope from behind my neck to in front of my face, I kind of swung it around, and the patient jumped. He almost jumped off of the exam table.”

Her work with a patient population suffering from PTSD, anxiety, and depression helped Elisseou understand the possible benefits of a trauma-sensitive approach. “[The physical exam] has the potential to reinforce the sentiment of care and establish rapport between physician and patient,” she says. “I wanted to create a safe space in the examination room where all patients felt comfortable, so we could establish a therapeutic alliance and work toward healing.” When she began teaching a small group section in the first-year Doctoring course in 2014, she incorporated many of the techniques she had developed.

Though she worked hard to use exam techniques specifically tailored to avoid re-traumatization of patients in her practice, Elisseou didn’t hear the term “trauma informed” until last year, when Meghna Nandi MD’20 and Srav Puranam MD’20 approached her after she led a workshop about the physical exam in trauma survivors. They explained to Elisseou that many of her clinical techniques fit into the formal conception of trauma-informed care: fostering feelings of safety, autonomy, and trust in the patient-physician relationship. “There was so much alignment,” Puranam says.

Shared Goals

Nandi and Puranam had discovered their mutual interest several weeks before that workshop, as they discussed one of their classes in the anatomy lab locker room. “In our Health Systems Science course, we were learning about a lot of really difficult topics like elder abuse, child abuse, intimate partner violence,” Nandi says. She felt the course often didn’t acknowledge that these issues may have affected people in the room. “Providers and health practitioners are also humans who are just as susceptible to experiencing all these things,” she says.

Puranam agreed, and they began to look for more places in the first-year curriculum that could better prepare students to care for patients affected by trauma and cope with the widespread phenomenon of vicarious trauma among physicians and trainees. Ultimately they decided a preclinical elective about trauma-informed care would be the most comprehensive way to introduce these concepts, and they asked Elisseou to be their faculty adviser as they developed the course.

While trauma often conjures images of extreme violence and physical injury, the range of events that can trigger adverse biological reactions and avoidance behaviors is much broader. A 2013 study published in the Journal of Traumatic Stress defined a traumatic event as one that produced physical injury, one that elicited fear of physical injury or death, or “any [other]extraordinarily stressful situation or event.” Using these criteria, plus follow-up questions to determine the context and severity of any such event, the authors concluded that 89.7 percent of participants had experienced at least one trauma. However, fewer than 10 percent of these participants showed signs of PTSD, which is a hurdle that Karen Johnson, MSW, LCSW, the senior director of Trauma-Informed Services at the National Council for Behavioral Health, sees in medical practice. “Only looking for diagnosable PTSD or another mental illness is a mistake,” Johnson says. “Trauma manifests itself in many different ways.”

Evidence points to an association between adverse childhood events and poor health outcomes later in life. In a survey-based study of 9,500 respondents from a single HMO group, published in the American Journal of Preventative Medicine in 1998, people exposed to traumatic events during childhood were found to have a tremendously increased risk for smoking, alcoholism, drug abuse, depression, suicide attempts, sexually transmitted disease, obesity, heart disease, cancer, lung disease, liver disease, and fractures.

So-called “high-risk behaviors” and their associated negative health effects only tell half of the story, however. Fears of re-traumatization during medical encounters, such as the physical exam, can cause traumatized patients to avoid the health care system altogether, compounding the effects of their physical ailments. Empowering patients by reestablishing feelings of safety, autonomy, and trust could help them overcome these fears. “When you experience something traumatic, you lose your sense of control over what’s happening,” Nandi says. Ideally, a trauma-informed approach restores these feelings to the patient in the medical environment, mitigating the cause of some of these negative health outcomes.

A New Framework

After Nandi and Puranam introduced her to the field of trauma-informed care, Elisseou began to assemble her physical exam maneuvers into the standardized framework she would ultimately teach in the Doctoring course. Though the concept of trauma-informed care has been around for decades, such a specific framework, focused on its application to the physical exam, did not exist. Elisseou’s framework includes specific language and behaviors to employ before, during, and after a routine medical exam in order create a safe environment and avoid triggers of prior trauma.

For example, in a traditional thyroid exam a physician will stand behind the patient, outside of the patient’s field of vision, and wrap their hands completely around the patient’s neck. Such a maneuver can trigger sensations of violent choking, she says. “This instead can be done with the practitioner standing at the patient’s side, within their eyesight, with the fingers extended, the thumbs away from the neck, and saying to the patient: ‘I am going to place my hands on the neck in order to examine the thyroid. When you can, please swallow,’” Elisseou says. “This lets the patient know exactly what you’re doing and why, and it avoids the sensation of choking.”

Elisseou’s thyroid exam highlights some of trauma-informed care’s basic tenets: remaining in the patient’s field of vision; explaining the procedure and its purpose clearly; and employing maneuvers that are intentional and sensitive to the feelings they cause. Similarly, Elisseou says having patients sit slightly upright during a pelvic exam both minimizes the patient’s physical vulnerability and allows them to maintain visual contact with the provider.

She also emphasizes the deliberate use of language in creating a trauma-informed atmosphere during the examination. “We hear physicians and trainees say ‘for me’ all the time when they’re giving patients instructions,” Elisseou says. “Sometimes this phrase can enhance the power differential between physician and patient, and can even, in certain cases, be sexually suggestive and inappropriate. For example: ‘swallow for me,’ ‘bend over for me,’ ‘lower your gown for me,’ ‘take off your shirt for me.’” She instead refers to parts of the patient’s body using the article “the,” rather than the more personalizing “your.” “It feels different to hear, ‘I’m going to look at your vagina,’ versus ‘I will now inspect the vagina,’” she says. She gives clear explanations and instructions as another way to enhance the patient’s feelings of safety, autonomy, and trust.

In spring 2017, Elisseou introduced her framework to students in an optional workshop, with hands-on practice. Student feedback was overwhelmingly positive. Sukrit Jain ’16 MD’20 says the workshop made him aware of his body positioning and language choice during patient encounters. “I always place myself in the patient’s line of sight now, and I try to inform my patients of the reasons behind my physical exam maneuvers,” he says.

Nandi, Puranam, and Elisseou were moved by such responses. “We’ve been so humbled by our peers, our colleagues,” Puranam says. “People we respect and look up to are finding value in this. It shows that our medical community is seeking a framework like this.”

The team is also excited about the potential of this framework to help providers cope with some of the insidious challenges of practicing medicine. A 2011 meta-analysis published in Academic Medicine found that students enter medical school with, on average, more empathy than the general population. Four years later, after completing undergraduate medical training, they are less empathetic than their peers outside of the medical world. More than ever, physicians identify the broad notion of “burnout” as the enemy of empathy. Elisseou sees a framework for trauma-informed care as a potential antidote. “I think that burnout inhibits our function on many levels,” she says. “However, when empathy is hard to call up and compassion is hard to find, we can rely on learned skills in the form of a trusty framework or a checklist that can still get the message across.” Puranam and Nandi add that helping providers better understand the contexts, histories, and environments of their patients could enable tired and frustrated students, residents, and physicians to harness empathy.

Last year Elisseou, by then the course leader for first-year Doctoring, decided to integrate trauma-informed care into the standard curriculum. She says the response has been positive: “I have gotten feedback from first-year medical students that this is an exciting subject that they look forward to practicing with patients at their mentor sites.” Vivian Chan MD’21 says that she has employed the skills she learned from that lecture during her weekly mentor sessions at the Providence VA. “It is a more empowering, and more comfortable, kind of approach,” she says.

Baby Steps

Elisseou’s framework fits into a wider scope of practices that create a trauma-informed environment within an organization, many of which occur outside of the exam room. “In a trauma-informed primary care setting, we know that all staff are equipped to identify and address trauma among the people they’re working with. They understand, recognize, and respond to all types of trauma and they always avoid re-traumatizing anyone,” the National Council’s Karen Johnson says. “People understand and embrace cultural competence and humility.” But this requires buy-in from all employees at a care center: custodians, receptionists, medical assistants, nurses, case managers, and physicians. The criteria for and implementation of these practices is not yet uniform, which has hindered their widespread adoption. The National Council is assembling a “change package” to guide primary care organizations seeking to become trauma informed, Johnson says, and she’s considering including Elisseou’s physical exam guidelines. “The goal is to create this tool that is actionable, usable, and consumable that primary care providers and everyone working in that setting will be able to take and use to move forward trauma-informed primary care,” she says.

Such comprehensive organizational change is not without its challenges. In primary care settings, “staff are often overwhelmed, and may feel ill equipped to meet the needs of people with long-term complex health issues,” Johnson says. “How do we create a tool that people can take and use and not put on the shelf? That’s our biggest challenge. We want it to be as usable as and as relevant as possible.” In her mind, a major component of overcoming this obstacle is the collection and analysis of data that prove that this slow and complicated process can lead to tangible impacts on patient health outcomes.

Recently, small studies have shown such benefits. In December 2016, the McSilver Institute for Poverty Policy and Research released their evaluation of the Trauma-Informed Primary Care Initiative (TIPCI), a small pilot program sponsored by Kaiser Permanente and the National Council. TIPCI tested the implementation of comprehensive trauma-informed practices at 14 federally qualified health centers using small Core Implementation Teams, each composed of employees in various positions at each site. After 10 months of on-site implementation, the 10 sites that responded to organizational self-assessment questionnaires at the beginning and end of the trial period all showed improvement, with the greatest progress associated with the largest time investments in data collection, patient screening, and workforce development. Critically, patients who received care at the centers participating in this brief trial showed some improvements in health outcomes, most impressively in management of diabetes. In one clinic, 75 percent of people categorized as having “high-risk” diabetes at the beginning of the trial were classified as having it “controlled” by the end.

“It’s very difficult for organizations to take the long view, to understand this is baby steps. This is years in the making—I would argue decades in the making,” Johnson says. “Some of the work is about making sure we do have the data to prove that this is what providers need to invest in.”

Ripple Effect

Elisseou will continue to refine the framework and, with Puranam and Nandi, collect data on its effectiveness in the medical education and patient care settings. They will publish a description of their workshop this month in Medical Education as part of the journal’s series on innovation in medical education. The team also will present the data they’ve collected at internal medicine grand rounds at the Providence VA; run a webinar for the SAMHSA-HRSA Center for Integrated Health Services; and plan to publish their findings in a peer-reviewed academic journal in the near future.

Already, Nandi and Puranam have noticed a cultural shift at school. They say their peers regularly share observations of the impact that the new practices have on their interactions with patients. Ultimately they envision trauma-informed care becoming an integral part of medical education beyond a single lecture or workshop. Nandi hopes it will be “the lens through which the Doctoring curriculum looks.”

Elisseou echoes that hope, finding inspiration in a potential ripple effect across the medical field. “That’s what makes me wake up early and go to bed late working on this—knowing that this can have an impact on real patients,” she says. The development, refinement, and integration of the trauma-informed physical exam framework will achieve a much simpler mission, she adds. “As long as we approach our patients with love, the outcome will usually be OK,” Elisseou says. “My hope in teaching the trauma-informed physical exam is to promote skills that communicate compassion, to have an impact on the way our patients feel when they are with us—I want them to feel safe, to feel loved. The mission of my life is love.”

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