Trauma is common in human experience, and clinicians must be cognizant of its impact on past, present, and future health of patients.
Lifelong Learning in Clinical Excellence | July 8, 2019 | 4 min read
The tone was angry, clipped, bitter despite my cheerful “welcome-to-the-practice” voice and outstretched hand. I was tired, so tired. Finally, Friday had come and here was an angry new patient. She seemed to be assuming I would let her down, disappoint. She seemed quite certain of it. The others certainly had.
She wanted to know how often I would see her, and did I understand why she needed her medications? She let me know that she reads her chart notes, all of them. The other day the specialists were talking outside the exam room, she heard them. She heard them talking about her and her condition. And her “angry demeanor,” she heard all of it, through the door.
So now we sit here. There is a long list of medications that she needs renewed. Some of them need to be certain brands, she has intolerances. I nod and say I understand, she is sensitive to medications, I have seen this before. She looks at me, really studies my face. I wait. I don’t push, I don’t look at my watch although it occurs to me I am quite late for my next patient.
“You know I am a Vietnam War Veteran.” I nod and thank her for her service. Awkward silence. And then I add, “that must have been a hard time to serve.” She answers in the affirmative, still looking at me, waiting, measuring my reaction. Then I ask, “what can I do to help?” She shows me a spot, it’s been there a while, it’s growing, she hasn’t felt like anyone would listen, couldn’t get an appointment. I tell her “I will.” And I do.
The metrics are not met at that visit, nor at the next one. Cautiously she and I talk, deviating from our cautious script: me being careful not to offend, she trying hard not to be hurt and disappointed by yet another “healer.” I learn over time that she was mistreated in childhood and joined the service at 17. She was assaulted in the military (I should know “that’s what happens to women”), still “better” than what happened at home. But then, (a pause . . . can she safely say this to me in this hurried oft-disappointing medical space?) her daughter was taken from her, did I know the story, it was all over the local news? She hands me a time-worn clipping from her purse. “Oh no,” I say, how sorry I am, “unthinkable.”
And it is beyond unthinkable, yet here she sits believing in medical care and possibly in me. She lives, she makes and keeps medical appointments hoping that someday she may feel ever so slightly better. I imagine my own children. Would something like that end me? Quite possibly. Yet here she endures arriving early to appointments, believing that health and healing are possible.
Trauma is common in human experience, and healthcare personnel and systems must be cognizant of its impact on past, present, and future health. Trauma-informed (TIC) care asks not “what is the matter with you?” but rather, “what has happened to you?” TIC recognizes the inherent risk well-meaning modern medical care has with its hurried encounters and constant hum of performance metrics to re-traumatize, to dismiss, to invalidate. Sometimes we have to take a step back, be the one observed, and earn the trust of our patients.
Admittedly, there will always be a lack of time, so developing a routine of respectful care during medical encounters can prevent the re-traumatization that patients like mine often experience in day-to-day medical settings. TIC also challenges us to consider what drives “difficult” behavior; it is important to understand that fear often resides underneath anger, and that a “difficult patient” may be in self-protection mode.
TIC in its person-centered approach holds great promise for promoting health and healing and is especially critical for populations at high risk for traumatic exposure, as trauma and its impact are not equally distributed in society. As such, an aspirational goal of TIC is to promote health equity and reduce health disparities. At a minimum, application of TIC can build trust and a sense of self-efficacy for patients.
Finally, asking a person “what happened to you?” instead of “what’s wrong with you?” also allows us to understand and validate the inherent strengths that the individual possesses, and enables us to collaborate in the service of wellness and healing. In healthcare, we have the unique opportunity to witness and assist in this process of growth and recovery.
The most beautiful people we have known are those who have known defeat, known suffering, known struggle, known loss, and have found their way out of the depths. These persons have an appreciation, a sensitivity, and an understanding of life that fills them with compassion, gentleness, and a deep loving concern. Beautiful people do not just happen. ~ Elizabeth Kübler-Ross