Photo Credit: Siarhei Khaletski
Part two of a conversation with Alex McDonald, MD, and Erika Roshanravan, MD, about trauma-informed approach to healthcare.
This is the second part of a series based on trauma-informed approaches. PW Editorial Board member and columnist Alex McDonald, MD, spoke with Erika Roshanravan, MD, medical director at CommuniCare+OLE, for a podcast episode about trauma-informed approaches and the need to shift the focus in patient conversations from “What’s wrong with you?” to “What happened to you?” If you haven’t read part one yet on the basics of this topic, start here now. Below are the final three points from their conversation.
1. What can doctors do if they want to start incorporating a trauma-informed approach into their practice, care, clinics, and organizations? Where can they go and how can they get started?
“There are three buckets to look at,” lists Dr. Roshanravan. “First, we’ve already talked about the organization culture and work environment change. When we talk about organizational change, downloading the principles of trauma-informed care from SAMHSA, looking at them, and starting to think about how this applies to your organization is a great way to start. Does everyone on our staff feel empowered? Do people feel safe enough to speak up when they see something? Is there transparency in communication? Do people ask for what they need? How are the power dynamics? We talk about being empowered, but power dynamics, especially in healthcare, are often pervasive, and our staff may not feel safe speaking up, or we may not feel safe speaking up to people who are higher up in leadership. Second is staff and physician education. A lot can be said for starting the conversation, ‘We realize trauma is common. Toxic stress is common. Healthcare is a stress inducing system. We work within an extremely abrasive system that is sometimes trauma inducing, stress inducing.’ We need to help people understand the effects that can have on our physical and mental health and our patients. Third, our interactions with patients and what we talk about with them, just start talking about it. Read up about it a little bit and intentionally start naming it when patients bring things up around trauma and stress. Naming that stress and trauma are common experiences, and yes, they do influence your life and care is important. Those conversations, listening, and acknowledging these experiences can be very, very powerful.”
“Sometimes, I think we, as physicians, get so busy in our day and doing a physical exam, listening to heart and lungs, for us, that’s completely normal, but for a patient, that can be very triggering in some situations,” adds Dr. McDonald. “Stopping and saying, ‘Hey, can I examine you?’ can go a long way. Same for asking more kind of open-ended questions, like, ‘Can we talk about your sexual history? Can we talk about your weight?’ I find that asking permission can change the dynamic in terms of the power differential in the room.”
2. What do you say to doctors who think this is silly or that they don’t have time for it?
“The reality is whether we like it or acknowledge it, the influence of trauma and toxic stress is still there,” asserts Dr. Roshanravan. “It’s still extremely common. It affects most of our patients. And it also affects most of us at some point in our lives. A trauma-informed approach can save us time and get us to the issues that are going on if we can name what’s happening and what’s important for the patient. I think we can say, ‘Oh, I’m not interested in this.’ But it’s right in front of us all the time, and naming it is powerful for us physicians.”
“When I was a resident, I had a patient who came in multiple times in a row for a lot of vague feedback,” says Dr. McDonald. “Finally, I got to the root issue: the patient was dealing with anxiety, depression, and a divorce. Had I been more in the moment and acknowledged or explored that more, it could have saved three or four office visits where they were prescribed multiple things they didn’t need. To your point, yes, sometimes it takes a little bit longer, but you invest in the beginning, and it’s ultimately going to create a better relationship, a better quality of care, and better health outcomes in the long run.”
“That’s exactly right,” agrees Dr. Roshanravan. “I recently had a young woman in my practice, this was her second visit for a fracture, who told me about childhood trauma. We had a conversation acknowledging the trauma and its impact, even on the current fracture. And she said, ‘I just wish that we’d had this conversation 20 years ago.’ I think these stories are powerful and happen all the time; people do want to talk about it. When someone feels skeptical about the importance of this kind of work, I highlight we are investing more and more into justice, equity, diversity, and inclusion, and there is no DEI work without trauma-informed approaches. We are considering all the cultural community and generational traumas, trauma from racism and inequity. We must use trauma-informed approaches, and those are inseparable. If we want to do DEI work, we must use these approaches. Same thing for physician wellness. Burnout is talked about so much in the healthcare industry, but is it addressed? We cannot do that without considering trauma-informed approaches. We can help, especially if we are in positions of leadership; we can help change organizational cultures that will be conducive to this collective care.”
3. Are there any specific conferences, books, or places you recommend for physicians who want to learn and engage more in this work?
“SAMHSA has published quite a few things on this topic,” explains Dr. Roshanravan. “I recommend the SAMHSA Practical Guide for Implementing a Trauma-Informed Approach. For more background information, I highly recommend watching Dr. Nadine Burke Harriss’s TED Talk on ACEs. She was the California Surgeon General for a few years and did tons of foundational work raising awareness. Some books include Bessel van der Kolk’s The Body Keeps the Score, which is very informative about how trauma and toxic stress affect us, and Bruce D. Perry and Oprah Winfrey, who wrote What Happened to You? The name of that book highlights a core principle in all this is to move away from asking ‘What’s wrong with you?’ and ask ‘What happened to you?’ The website ACEs Aware has training physicians in California must complete to bill for ACEs screening, but I recommend it to any physician. Finally, if you are interested in how this connects with physician wellbeing, look at publications by Tait Shanafelt, MD.
