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Criticizing ACEs in Peer Reviewed Professional Journals Impairs Child Abuse Treatment

 

As a family doc practicing in San Diego, I was privileged to hear Dr. Vincent Felitti talk about his inspired development of the CDC-Kaiser Permanente Adverse Childhood Experiences Study (ACE Study) and the link between ACEs and many adult mental and physical diseases directly from him only a few years after his original insight.

Yet, although I had a lively clinic and learned how to manage a vast array of medical conditions over the next 25 years, like most primary care providers I never paid attention to the importance of childhood maltreatment and trauma. Then, when I was treating a couple of homeless patients whose history of child abuse resulted in a very handicapped adult existence, I received little support from my clinic colleagues, but discovered the depth of the resources in our community that were focused on this problem. After 35 years in practice this was the first time I ever heard the phrase “Trauma Informed Care.” A bit more exploration confirmed that medical professionals (except pediatricians),  generally whether by culture, shame, ignorance, neglect, misplaced priorities, or confusion, largely overlook the specific needs of the many adults (about one in seven) who had been traumatized as children, in their policies and protocols, in their training, and in their clinical practice. This must be changed, since trauma due to child abuse and/or neglect can have a major effect on adult health and function.

Lately there has been a series of articles in the various peer reviewed medical journals (1,2,3,4,5) that, in discussing  screening for child abuse and neglect trauma after recognizing the powerful epidemiological prevalence studies, emphasize the problems of using an ACEs or similar screen rather than the importance of stepping up to take responsibility and facilitating expansion of treatment capabilities. Recently these articles seem to be a critical reaction to the California ACEs Aware initiative. Perversely this results in important, widely read medical journals conveying a sense that there are good reasons for the average practitioner not to become involved, not to screen, not to bother and not to take responsibility to treat adults harmed by childhood trauma, thus re-enforcing barriers to care.

  • The first criticism is that the ACEs screen is a simple minded score and is not a validly standardized measure of childhood exposure to the biology of stress. Merely adding dissimilar experiences with equal weights as different exposures have a differential impact; omitting many possible equally traumatic factors; not discerning age and sex may have differential response to an adverse experience; not evaluating experience clusters; not assessing  the frequency, intensity, or chronicity of exposure; not having a precise threshold for significance; being subject to both positive and negative recall bias and omitting positive experiences which build resilience and minimize impact. These factors are certainly important, especially for research, and peer-reviewed journals are the place to discuss them, but these nuances are not important in the primary care clinic except as they pertain to the care of a specific patient. On the contrary, simple and quick is an advantage. In fact, an even more simple approach may be more practical. It would be just as functional to replace the ACEs screen with a single “universal precaution” question such as “When you were a child did you ever have experiences that were very upsetting, tragic, physically or emotionally harmful, or so painful that may impact your life now? If so, it may be beneficial to talk about them and I am ready to listen.” The ACE survey is a simple tool to start a conversation about an existing pathogenic problem that may be unrecognized or previously unrevealed. (Currently the California project is also using it as a tool to educate doctors about childhood trauma’s contribution to disease.)
  • The second criticism is that the ACEs screen can be offensive and will cause respondents to be offended or upset by answering personal questions about ACEs and thus erode the trust between clinician and patient or parent. This overlooks a large body of clinical experience focused on the art of medicine. Clinicians using the ACE survey rarely encounter an offended or uneasy patient. In any case, a defensive patient can avoid this issue by giving negative responses. On the contrary, often patients express explicit gratification for opening up the conversation, often for the first time in the patient’s life. The ACEs screen can provide the beginning of a more intimate, honest, and intense doctor-patient relationship. Just getting the issue out can give the patient great therapeutic insight and benefit. Empathic listening and support is of the essence and, in some cases, this alone can provide the gateway to improvement. This perspective is re-enforced by the experience with now nearly universal acceptance of screening for domestic violence.
  • The third criticism is that offering an ACEs screen without proper training, attention and follow up is harmful. This is a practical valid concern. Questions about traumatic experiences are deeply personal and potentially painful and distressing. Inattention or poor follow-up in the clinic to a positive screen can cause more harm. Using the ACEs screen requires careful planning, training, and resource allocation. The California Aces Aware initiative has wisely built practitioner training into its program.
  • The fourth criticism is that the ACEs screen will pejoratively label patients and cause investigation of healthy patients who have experienced positive or remedial factors creating resilience. This criticism seems to reflect projected continuation of the cultural attitude of shame toward child maltreatment experiences. Any practitioner using the ACEs screen must always be ready to acknowledge a positive screen with an extension of empathy and lack of judgment. A positive screen must always be considered in the context of the patient’s actual complaints. Medicine does not have the needed resources to evaluate and treat all the patients who have had childhood trauma and want help, never mind devoting resources to patients who had childhood trauma and are doing well. No claim has been made that a significantly positive ACEs score predicts future disease in an otherwise healthy patient.
  • The fifth criticism is that the ACEs score is a poor tool for preventive medicine screening. This is a paradigm distortion. Screening for childhood trauma in adults is not for primary prevention. The screen is not to assign risk, but to identify current problems. It is for disease case finding and may improve the treatment of alcoholism, chain smoking, hypersexuality, depression, anxiety, sleep disorders, obesity, cardiovascular disease, diabetes, among others, as well as problems with relationships and social skills.
  • The sixth criticism is that ACEs data has provided epidemiological knowledge only. The claim is made that ACE scores are associated with increasing population risk of health and social problems, but they cannot be applied and are not predictive at the individual level. Knowledge about epidemiology, however, can set priorities and draw attention. In fact, this is true throughout medicine with most diseases. Epidemiology documented an explosion in lung cancer cases and then (with controversy) validly linked it to smoking, but could not identify which smoker would get lung cancer, so medicine undertook the task of preventing smoking generally, both in the community and in individual patients to great benefit.
  • The seventh criticism is that primary care clinicians do not have the time to implement the ACEs screen. This might be accepted but for the fact that child abuse trauma is so common and intertwined with so many mental and physical disease processes that it can no longer be overlooked. Using ACEs is a tool to educate physicians as well. Using positive screens as a start will improve care and outcomes across the board. Undoubtedly, taking on the issue of child maltreatment trauma will stress the busy clinic by requiring an expanded paradigm for management. Occasionally among adult patients and more frequently among children mandated reporting to legal authorities is required. This may be stressful, make the practitioner uneasy, fracture the usual expectation of patient confidentiality and be time consuming. There is no established quick therapy like a medication. (Existing psychiatric pharmacology is notoriously ineffective.) Empathic listening and support is of the essence and can provide the gateway to improvement without a commitment to extended talk therapy. On the other hand, a “fifteen minute hour” of trauma informed cognitive behavioral therapy frequently repeated can be quite successful. Optimally an easy referral for ongoing care is available for trained trauma informed counseling. Physicians also need to be trained to focus on and intervene in the contribution of child maltreatment trauma to many adult chronic diseases such as asthma, emphysema, obesity and irritable bowel syndrome, among others.
  • The eighth criticism is that no interventions have been shown to improve outcomes for children or adults who report a high number of ACEs is flatly wrong. There are a myriad of reports (not experiments – which may be unethical in some circumstances) especially by psychologists and social workers on specific counseling techniques that are beneficial. Simple identification and empathy are very important. The elements of trauma informed care are continuously being elaborated. Innovative techniques like eye movement desensitization therapy (EMDR) in PTSD may be effective. Even though the long term effects of child maltreatment trauma were established 40 years ago, much of the attention has gone into describing the morbidity in children and intervening there. The very outline and extent of its effects in adults is still in the process of exploration and documentation. Structuring good treatment and outcome studies on an evidence based basis has yet to be accomplished due to (a) low priority at the NIH, (b) denial of pathogenic significance by American psychiatrists, (c) naturally low advocacy by the families and patients involved, (d) continuing societal shame and avoidance, and (e) ongoing medical ignorance of child maltreatment trauma’s significant impact on health throughout the life cycle (6,7).


It seems to me that general medical journals bear a responsibility to put these considerations in context by increasing publications that emphasize practical clinical considerations in the management of child maltreatment trauma by front-line practitioners. In particular many of the issues raised are straw horses that have an out-sized negative effect on practitioners and raise the threshold for initiatives to provide needed care. Meanwhile practitioners caring for patients who have experienced child abuse trauma should not be confused nor inhibited by these critical articles.

All of us should join in professional advocacy to raise sensitivity to the prevalence and impact of child abuse trauma in the medical community, to promote treatment by a broader array of practitioners, and more attention to supporting prevention and treatment in the public policy arena.

REFERENCES

  • Campbell TL. Viewpoint, Screening for Adverse Childhood Experiences (ACEs) in Primary Care: A Cautionary Note, JAMA Published Online: May 28, 2020, doi:10.1001/jama.2020.4365
  • Baldwin JR, et al, Population vs Individual Prediction of Poor Health From Results of Adverse Childhood Experiences Screening, JAMA Pediatr. 2021; 175(4):385-393. doi:10.1001/jamapediatrics.2020.5602
  • Anda RF, Porter LE, Brown DW, Inside the Adverse Childhood Experience Score: Strengths, Limitations, and Misapplications, Am J Prev Med 2020;000(000):1−3,doi.org/10.1016/j.amepre.2020.01.009
  • Austin AE. Screening for traumatic experiences in health care settings: a personal perspective from a trauma survivor. JAMA Internal Medicine, Published online May 3, 2021. doi:10.1001/jamainternmed.2021.1452
  • Finkelhor D, Berliner L, Screening for Traumatic Childhood Experiences in Health Care Settings, JAMA Internal Medicine, Published online May 3, 2021 E1
  • Machtinger EL, Lieberman A, Lightfoot M, Research, Practice, and Policy Implications of Adverse Childhood Events, JAMA Pediatr. Published Online: May 10, 2021.doi:1001/jamapediatrics.2021.0810
  • Krugman R, Narrative Matters, Ending Gaze Aversion Toward Child Abuse and Neglect, Hlth Aff, 2019; 38(10):1762-1765. doi:10.1377/HLTHAFF.2019.00573.

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@Jeoffry Gordon: If you had written this comment as your blog post, i would have not likely responded.  It is right on point!  I disagree with nothing.  You captured the sentiment much better than I could have.  The problems with kids and families (and communities) cannot be solved by healthcare (alone).  As I say regularly, "Healthcare is not the Solution, but it part of the solution."  Kids and families (and communities) struggle due to political/social/cultural/economic forces, and it is those forces that need to be engaged...and healthcare is poorly equipped to work in these spaces (although they could be much better than they are).  We thought through what we would propose the "Pediatric Office of the Future" would look like: https://www.texaschildrens.org...20Report%20Final.pdf

I guess my concern is that people think that the solutions to these ills lay in the medical office.  It does not.  They lay at the ballot box.

Thanks for prompting the discussion!

Cheers,

Chris

I am pleased to have  created such a thought provoking dialogue among colleagues - as was my purpose. Left unsaid by me was my understanding of the natural conservatism and inertia in the House of Medicine and the role of professional journals in creating the molasses of progress. (Some colleagues I know are paranoid - or insightful? about this.) The general medical journals are eager to publish articles about the  difficulties with ACEs utilization and hesitant to publish more discursive and clinical discussions about child maltreatment pathodynamics and treatment challenges. My 8 points are meant to support clinicians to keep working with victims in spite of "professional" skeptics.

Professor Greeley's thoughtful and pointed analysis is  a golden nugget in this dialogue as he is a very clinically experienced and admired advocate for children. His points and perspective are well informed, well thought out and experience based. I cannot debate them. Since he does refer to Michael Marmot, the godfather of social medicine and clinical epidemiology and a hero of mine, let me start there........

The basic problem is that child maltreatment is largely a social pathology; the result of a coarse, capitalist and pseudo-Christian society where support of family life ends when the fetus is born and national resources flow toward the one percent. In this world the family is adrift on a sea of challenges with no life rafts: poor housing or high rents; poor jobs or no livable wage; neighborhood violence; food insecurity; underfunded public education; no day care; no maternity leave; second class health care (known as Medicaid); and racial animus. In this environment the best parents would have trouble dealing with child energy. Marmot's students described and predicted all this in a fine book called THE SPIRIT LEVEL (by Wilkerson and Pickett), published in 2009. Those of us who work as clinicians in this field are privileged to give succor to the wounded (and are not deterred by the lack of subtlety or rigor in the ACEs tool), but let's face it we are just putting band aids on a social catastrophe. Surely the journals can easily ruminate about the lack of good outcome studies - it is easy to do. The real problems originate outside the medical paradigm - unless you think boldly like Rudolf Virchow (1821-1902), a pathologist and one of the fathers of modern medicine who famously said, "Medicine is social science, and politics is nothing but medicine on a large scale."

Thus inspired I say (1) the ACEs tool or using a universal one question inquiry must be ubiquitous to open up the dialogue with those who silently suffer in shame; (2) there are many adults who have suffered adverse, disease and disability induced effects from maltreatment as children [~15% of the population] who will benefit from medical intervention.  Many of us are able to avoid the fact that the epidemiology of child abuse and neglect tends to overlook institutional populations such as the homeless, prisoners, juvenile hall, and the military where the prevalence of child abuse trauma may run as high as 2/3; (3) the medical/counseling paradigm does give us tools to augment our compassion to facilitate healing [but note the usual medical tools of pills and surgery are basically ineffective]; (4) the current bureaucratic, tightly scheduled, specialized medical system is ill suited to deal with this problem; (5) the medical paradigm always needs to be pushed to expand its capabilities - see smoking, seat belts, HIV successes and covid failures; (6) As McEwan, Greeley and others eagerly point out we lack any good proof medical intervention improves individual or population outcomes. Hell's bells! We have only been looking at this problem for 2 generations. Psychiatry still does not recognize child abuse trauma as an illness, major public institutions from the legal system, to the military to criminal justice still turn their gaze away in shame and neglect. Studies with control groups would be unethical; and so (7) I suggest everyone involved in the child maltreatment arena needs to tithe 15% of their time to political activism in their community.

Thank you for writing such a thought-provoking piece.

As an ACE Screening Skeptic (I believe in the principle that childhood/family adversity has meaningful impact on health and wellbeing as an adult), i think that the cart is before the horse.  I would not frame your criticisms as criticisms, but as characteristics.  My three biggest concerns (from the pediatric practitioner perspective) are: (1) it is unclear the "correct" adversities to "screen" for.  Why not bullying? Why not racism? Why not transportation? Why not school failure?  Why not food insecurity?  (Don't get me started on treating them all as "1"(equally) or not accounting for the age at which the event(s) happened). (2) There are not data (as noted by Craig McEwan) that broad screening for "ACEs" improves population outcomes.  This does not discount the anecdotes of instances in which individuals may be helped (as noted in the other comments).  There will be also instances in which individuals may be "harmed", but those will not be as readily recounted.  Recent data from multiple studies demonstrate that "ACE" score is a poor predictor of individual health outcomes. (3) The biggest issue is not "should we screen" or "Is screening possible", but "what do i do about a positive screen".  It is not the practitioner time issue that you outline in criticism 7; that can be overcome with planning, staffing and patient flow analysis.  The bigger issue is WHAT is the best thing to do for the patient?  I fear that a broad implementation of ACE screening will result in children/patients with scores (a la Scarlet Letters) without appropriate mental, behavioral, social, economic, educational responses.  If ACE screening is positioned as just one vehicle to introduce a trauma-informed (whatever that means) dialog with patients about their chronic diseases and the role that their childhood could play in it, then I'm onboard.  But the emphasis on scores and numbers and the specific "historic" ACEs is problematic.

Also:

The power of the original (and subsequent) published data evaluating ACE scores is not the scores per se, but the gradient effect on health outcomes.  I regularly noted by Michael Marmot (See his book The Health Gap), the public health gradient is a potent predictor of severity of outcomes.  The operationalization of ACE screening should appreciate that.  Not focusing on positive vs. negative, but the gradient effect of worsening adversity histories being associated with worsening outcomes.

Also Also:

The title of this piece (Criticizing ACEs in Peer Reviewed Professional Journals Impairs Child Abuse Treatment) is a poor choice.  (A) There are not criticisms of ACEs, but wholesale ACE screening, and (B) framing the debate as "Child Abuse Treatment" doesn't work, in my opinion.  I also don't agree that the discussion of the strengths and challenges with ACE screening somehow "impairs" it.  I say this as someone with >20 years of working as a Child Abuse Pediatrician.

Last edited by Jane Stevens (PACEs Connection Staff)

As one of the critics of the misuse of ACE scores (not of ACE research and its important implications for public health),[1] I was interested to read your call for a halt to such critical commentary.  Of course, the most prominent critic of ACE screening in the pediatric setting is Dr. Robert Anda who co-authored the original ACE research.[2]

Thank you for the summary of criticisms of ACE screening. I would add at least one more – the ten ACE items in the typical screen do not capture the wide range of adversities that contribute to toxic stress in children and adults.

You make the important observation that ACE ‘screening’ may be a useful tool for adult patients who face health challenges. The same may be true for using a version of an ACE survey for parents. Focusing on past childhood adversity and trauma may be a very helpful avenue for treatment and for helping parents understand their relationships with their children. As you point out, on the treatment side, “It is for disease case finding and may improve the treatment of alcoholism, chain smoking, hypersexuality, depression, anxiety, sleep disorders, obesity, cardiovascular disease, diabetes, among others, as well as problems with relationships and social skills.”

The fifth criticism is fundamental and your response turns attention from problematic pediatric screening to the potential utility for adults and adults, noted above. This retrospective use of scores for adults is very different than their predictive use in pediatric visits as Dr. Anda and colleagues point out. There is very strong evidence that ACE scores are poor predictors of individual health, even if combined with some measures of positive childhood experiences. Nor does the use of de-identified ACE scores (not revealing which items were checked off) in California lead to a focus on child abuse which should certainly be attended to by pediatricians. In pediatric settings, developmental screening (which was poorly implemented in California ten years ago according to KIDS COUNT – unfortunately no more recent data are available) would appear to be a much more direct measure of health and behavioral issues for children.

Your sixth criticism is not really a criticism – it is an appreciation of the value of ACE data and other evidence about the social distribution of adversity in populations for making public health and other policy choices. Indeed, just as epidemiological data were used to connect the risk of cancer to smoking, linking childhood adversity to childhood and adult health issues should point us toward policies that reduce that adversity and promote healthy development. Diminishing childhood poverty and providing supports for families such as high-quality child-care are among such policies.

We share a goal of reducing adversity and creating healthy environments for kids (and adults). Forgoing thoughtful criticism and ignoring evidence will not get us there. So let the debate and discussion continue!



[1] McEwen and Gregerson, “A Critical Assessment of the Adverse Childhood Experiences Study at 20 Years,” Am J Prev Med. 2019 Jun;56(6):790-794.doi: 10.1016/j.amepre.2018.10.016. Epub 2019 Feb 23.



[2] Anda, Porter and Brown, “Inside the Adverse Childhood Experience Study: Strengths, Limitations, and Misapplications,” Am J Prev Med. 2020 Aug;59(2):293-295.  https://www.ajpmonline.org/article/S0749-3797(20)30058-1/fulltext

Wow. What a difference just this simple question could have made, so many times as I was treated for asthma, stomach issues, a bad back, chronic pain, etc.:

“When you were a child did you ever have experiences that were very upsetting, tragic, physically or emotionally harmful, or so painful that (they) may impact your life now? If so, it may be beneficial to talk about them and I am ready to listen.”


Thank you for this thoughtful, thorough (I am not a doctor or an MPH but I have heard many of the arguments against screening and I believe every negative I have heard was been addressed here, such as the fear of asking the questions evoking a snot-slinging, fall-apart meltdown, which apparently rarely happens, or that the information is weaponized against the patient. I am still not sure how a score being written into a medical record could not be used when one is applying for new insurance should pre-existing conditions come back into play. Also, looking at positive childhood experiences (PCEs) and their ability to buffer the impact of ACEs is worth a look. And where there is the will, there is a way to operationalize PCEs, and to even make positive experiences part of a treatment plan. Friend of PACEs Connection Dr. Daniel Sumrok, a brilliant physician, expert in addiction science, and a professor, prescribes to patients experiences such as “coach a little league baseball team” and such to get them up and outside of themselves to find pleasure in life again.

Though many other thoughts about what you have written come to mind, the prevailing one is gratitude for what I believe is the medical art part of how you are thinking about and caring for your patients. I am also grateful for your advocacy of using the science to it maximum good purpose. In an article by Dr. R.J. Gillespie, an Oregon pediatrician, he advocated for using the the survey to build relationships, when “ACEs are assessed and empathetically assessed during the course of a visit.”

He writes, “My practice incorporated parental ACEs Screening.

What a difference just this simple question could have made, so many times as I was treated for asthma, stomach issues, a bad back, chronic pain, etc.:

“When you were a child did you ever have experiences that were very upsetting, tragic, physically or emotionally harmful, or so painful that (they) may impact your life now? If so, it may be beneficial to talk about them and I am ready to listen.”


Thank you for this thoughtful, thorough takedown of the arguments against using the ACEs survey for improved patient care.

I am not a doctor or an MPH but I have heard many of the arguments against screening and I believe every negative I have heard was addressed here, including the fear of asking the questions evoking a snot-slinging, fall-apart meltdown, which apparently rarely happens, or that the information would be weaponized against the patient. I am still not sure how a score being written into a medical record could not be used when one is applying for new insurance, should pre-existing conditions come back into play.

Also, looking at positive childhood experiences (PCEs) and their ability to buffer the impact of ACEs is worth a look. And where there is the will, there is a way to operationalize PCEs, and to even make positive experiences part of a treatment plan. Friend of PACEs Connection Dr. Daniel Sumrok, a brilliant physician, expert in addiction science, and a professor, prescribes to patients experiences such as “coach a little league baseball team” and such to get them up and outside of themselves to find pleasure in life again, and experiences tremendous success as is evidenced by the number of patients who maintain steady employment during and after treatment in his clinic.

Though many other thoughts about what you have written come to mind, the prevailing one is gratitude for what I believe is the medical art part of how you are thinking about and caring for your patients. I am also grateful for your advocacy of using the science to it maximum good purpose. In an article by Dr. R.J. Gillespie, an Oregon pediatrician, he advocated for using the the survey to build relationships, when “ACEs are assessed and empathetically assessed during the course of a visit.”

He writes, “My practice incorporated parental ACE screening into our clinical workflows over seven years ago, and we’ve used the information to better understand early childhood health and development. Our initial intentions were simple—if a parent has experienced ACEs, what do they need or want in terms of resources and support? If a parent has experienced ACEs, how can we help them to break the intergenerational transmission of trauma? We thought the best way to figure that out was to ask if parents have experienced ACEs, and then what resources they would find most helpful.

"Since then, we have learned that parental ACEs had a negative impact on their child’s developmental trajectories1, and on utilization patterns including frequency of well visits2. This makes conversations about parental trauma (and other family stressors) an important and integral part of the conversations about how we help children with developmental risk. To me, this means that ACEs assessments are really best utilized in the context of supporting a child’s development and social wellness, rather than as a one-off kind of screening tool. For example, there’s a difference in the clinical workflow for a failed developmental screen if there is a history of maternal depression, parental ACEs, or other social determinants of health versus how we respond if none of those things are present. It’s not enough to simply refer everyone for early intervention if we don’t have an idea of the factors that might make it difficult for the family to use such resources."

Dr. Gillespie, too, is applying the medical art of using an instrument, the ACEs survey, to gain understanding, build trust, establish relationships, improve outcomes.

Thanks again for raising the objections and addressing them.

Whether the rest of the medical cognoscenti is pro or con for the screening, what is apparent is a massive lack of understanding of the impact of trauma, and different types of trauma, on patient outcomes, as we see evidenced in the horrific health disparity between Black and White maternal and infant mortality. Black women are about three times more likely to die from a pregnancy-related cause than White women. And of course the pandemic has, as has been said, laid bare health care disparities that have always existed.

I commend your bringing up all these points and hope medical schools, nursing, and allied health educators as well as the editors of medical journals will pay attention to what you have written. There is a lot more right about asking the questions than there is about ignoring the root cause. No doubt many more people such as I  who have high ACE scores would have benefited from having greater understanding about why maintaining our health has been challenging.

I am only a study of one, but I know in recent years, having a greater understanding of my developmental trauma has inspired and empowered me to practice improved self-care, and that my knowing some 21 years ago that my ACE score could shorten my life by 20 years prompted this single mother to do everything I could to be healthier; stay healthier, not leave my children with the legacy of a mom who was done in by the past; who repeated multi-generational addiction and abuse.

Knowledge is power. Relationships are invaluable. Medical school curricula needs to emphasize PACEs science and the importance of physicians using it to foster patient empowerment and trust. Empowerment and trust are healing, and are likely good examples of physicians understanding the "art" part of the medical arts.

Carey Sipp

Last edited by Carey Sipp (PACEs Connection Staff)
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