Don’t ask “what is wrong with you.” Ask “what happened to you.”

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By: Bernadette Kiraly, MD

She had resettled in Utah from Africa as a refugee, fleeing a horrific past where she witnessed her husband’s murdered and she was beaten by soldiers. I prepared myself for the onslaught of pain complaints with the unreasonable expectation that I was going to fix it for her. I knew her pain was likely “life pain” and not entirely physiological pain. I entered the room feeling hopeful that I could help her. Initially, the visit went as expected but soon changed dramatically. She started to discuss her headaches and that she was beaten unconscious by soldiers in the past. As I listened she gradually slumped forward, clutched her head in her hands, and stopped talking. As she just sat there, I stopped the interview, gentled asked what she needed, cracked the door ajar, and offered her some water. Obviously, the visit was over. We were not going to get “anything”  done, but it did give me a glimpse into the depth of her pain and trauma. When I get out of my medical mindset of “fix it,”  I did get something done. We started to build the trusting relationship she needed to address her medical issues and trauma.

This patient is a real person and she also represents a growing population. Utah has been a refugee resettlement city since 1983 and is now home to over 50,000 refugees. Of those, an estimated 17,500 are trauma/torture survivors(1). Unfortunately, trauma and the long-term consequences are not unique to refugees. The CDC-Kaiser Permanente Adverse Childhood Experiences (ACE) Study, published in 1998, demonstrated that there is a relationship between exposure to abuse or social dysfunction during childhood and adult disease burden, including some of the leading causes of death such as heart disease and cancer(2). The study also found that adults who reported four or more ACEs, when compared to adults with zero ACEs, had a 4-12 fold increased risk of alcohol use disorder, substance use disorder, depression, and suicide attempts. The prevalence of patients with ACE scores greater than or equal to 4 was 12.5 percent.  So roughly 10 percent of the study population had signification childhood trauma, which means if we generalize this to our patient population, this is significant.

The experience of trauma can negatively impact a patient’s engagement in the health care system. These patients may repeatedly miss or cancel appointments, avoid preventive care, show poor adherence to care plans, have chronic unexplained pain, and have excessive anxiety about medical procedures. We sometimes label them as a “no shower,” “non-compliant,” and “frequent flyers,” which are neither flattering or accurately describing the root problem. These patient behaviors are difficult because they have a negative impact on doctors’ metrics for success (revenue and quality) and additionally create barriers to care and healing. As doctors, we are measured on how many visits we perform, the percentage of patients getting preventive services, and how well they adhere to our medical recommendations.  It is easy to just want to dismiss the patients, but I suggest we resist this urge and instead lean in with Trauma Informed Care.

When I am faced with a trauma patient who exhibits these behaviors, I try to put their experience in perspective. I ask “what happened to them” and not “what is wrong with them.” This paradigm shift is the essence of being a trauma-informed provider.   According to the Substance Abuse and Mental health Services Administration, the concept of a trauma-informed care follows four R’s.

  • Realizes the widespread impact of trauma;
  • Recognizes the signs and symptoms of trauma in patients;
  • Responds by fully integrating knowledge about trauma into policies and operations, and
  • seeks to resist Re-traumatization(3)

At an individual provider level, there are six patient care elements: Safety, Trustworthiness and Transparency, Peer Support, Collaboration and Mutuality, Empowerment, Voice and Choice, Cultural, Historical, and Gender Issues. I observe many of my primary care (and specialty care) colleagues display these elements (except the peer support) and many of the elements of the Patient-Centered Medical Home reinforce them. The next steps should be to do patient care with full awareness, develop more robust referral pathways with trauma-informed behavioral health providers, look at our healthcare system as a whole and how we can integrate these principles throughout, and study the impact of this investment. Currently, there is no evidence that Trauma Informed Care has an impact on quality of care in the primary care setting. However, the patient comments seen in our Patient Satisfaction Surveys lead me to believe patients benefit from it. They feel heard and valued. I’ll end with a quote from a patient that demonstrates this.

“My care team has given me hope and optimism that I will get well again. I am so happy and grateful to have her in my life helping me on a path to wellness.”

  1. https://www.uhhr.org/survivors-in-utah accessed 9/14/18
  2. https://www.cdc.gov/violenceprevention/acestudy/about.html accessed 9/14/18
  3. https://www.samhsa.gov/nctic/trauma-interventions accessed 9/16/18

Bernadette Kiraly

Bernadette Kiraly, MD, is an Associate Professor (Clinical) in the Division of Family Medicine in the Department of Family and Preventive Medicine at the University of Utah. Dr. Kiraly currently practices at the Sugar House Health Center.

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