Not my what my doctor said! When I asked her if she had considered screening all patients for childhood trauma, she said, "oh, we know who to ask."  I was stunned. We had just completed the paperwork for my medical leave from work one day/week for chronic PTSD. She was completely ignoring the fact that a) she had never asked me anything about my background and b) I had told her the PTSD is due to childhood trauma.

She has never asked for any additional information. I would think she would want to know if I was sexually abused, for example, since that could have major consequences for medical exams. I haven't pressed any information on her, since she is clearly not ready to hear it.

I would like to see a day when all doctors' practices screen all patients at intake, and ask questions about traumatic experiences during annual exams.

Actually, since I went through the trauma of dealing with an abuser in my family attending my own Mother's funeral against my wishes and was devastated when my family turned on me instead of directing their anger at the abuser in the family, I was emotionally devastated and talked to my internist and my rheumatologist afterwards, and have been talking about it ever since. I view it as part of my medical history which affects how they treat my conditions. Auto-immune disease like my rheumatoid arthritis are affected by emotional distress.

Hi Jane,

I had never once heard about ACEs in all four years of medical school, and I never heard of "trauma-informed practices" either. 

This year, as an MPH student, I learned about trauma-informed practice through my efforts to create a sustainable collaboration between a student-elective I started on Oral Health and Healing Hurt People.  I decided to take Sandy Bloom's course "Violence, Trauma & Adversity" this quarter, and that is when I learned about ACEs.  This was truly my "Aha" moment!  

  Looking back on my third and fourth years of medical school I now realize that if I had known about ACEs and trauma-informed practice my approach to patient care would be very different. 

The need to embed a trauma-informed practice curriculum cannot be overstated!  I am working on writing a paper on what such a curriculum might look like for Sandy's course, and for submission to our curriculum committee.   

Does anyone know of existing models? 

sam

Very interesting, Sam. 

Nancy Hardt is prof who's been embedding ACE education into the med school at the Univ. of Florida. You can contact her through this network. 

Geez, this just came up in the news today:

"The rest of the family did not understand why Rosario [59yo] did not rally around his cousin's illness, did not attend his wake, nor his funeral. They did not understand what had happened so many years earlier...."

http://acesconnection.com/profiles/blogs/pioneer-press-columnist-tells-personal-story-of-child-abuse

Chris, This is uncanny! It was our cousin who also was the abuser. There are people in my family who know, but no one in HIS family knows. It's the worst kept secret that almost everyone else knows. And I am te only one talking, confronting, dealing. And everyone else shuns me for it. It is such a devastating experience. Decades later.

Late to the discussion, but it caught my eye because Dr. Felitti will be conducting a break-out session for physicians at our conference in Los Angeles on March 19th (1-2:30pm).

This is how we've been talking about it:

Integrating A Comprehensive Medical History into Everyday Practice

Although the implications of the ACES study now permeates health and social services and the questionnaire is being implemented in 20 states and 14 countries in the world (through WHO), many physicians are unaware of the study and wouldn't know what to do if someone brought them their ACES score.

We invited the doctors from Kaiser Permanente but they have a mandatory training that day. If you know any physicians, please be sure to pass the information along. Here's the link

http://www.echoparenting.org/professional-services/conferences

We have a price for the whole day(s) of the conference, but if there were physicians who were only able to come for the break-out we would work with them on price.

Thanks!

Louise

PS Jane, are you still coming?

Kathy -- While we're waiting for Dr. Felitti's response, I'll provide some info....here's Dr. Felitti's post about how he integrated ACE screening at Kaiser:

How we integrated ACE screening into the Health Appraisal Center at...

Also, family services in the public health dept. in Port Townsend, WA, is screening for ACEs -- http://acestoohigh.com/2012/03/23/public-health-clinic-adds-child-trauma-to-smoking-alcohol-hiv-screening/

And Dr. Nadine Burke is screening for ACEs in her pediatric practice in San Francisco. She did a webinar for the  American Academy of Pediatrics about it.  

Personally speaking, I would want nurse practitioners and physicians to be able to talk about this with a patient, especially since they may need to change their approach and treatment. It's a physical and mental health issue.  

-- J.

Here's a link to the chapter Sam references:

The Relationship of Adverse Childhood Experiences to Adult Medical Disease,  Psychiatric Disorders, and Sexual Behavior: Implications for Healthcare.

http://www.theannainstitute.org/LV%20FINAL%202-7-09.pdf

Thanks, Sam. I think you're exactly right on both points, and I think the first point, that many docs are avoiding their own past trauma, is a major factor. 

Chris posted a link to the paper you mentioned, which I checked out and realized I have that paper. Just haven't read it yet! So now I'll move it to the top of the pile.

Best,

Kathy

I really love this website!

Thanks, Jane!

Thank you, Jane. I have printed out that post, and will read the Port Townsend info as well.

Yes, I said "nurse" in the post above, but in fact it would either be a nurse practitioner or a social worker do the follow-up after the doctor has addressed the issue in the appointment. In Vermont, most practices are enrolled in the state-wide Blueprint for Health, which provides the practice a team of care coordinators. There are always nurses and usually social workers on these teams. In drafting the screening guidelines, we consider these teams a critical piece to get past the screening barrier of "I don't have time for that."

BTW, we have Dr. Felitti coming to Vermont in October for a state-wide conference on ACE, aimed at primary care physicians, their teams, and community service providers. We're designing the conference using Dialogue Education, which is based on adult learning research, so that everyone will engage with the information at the conference, and have breakout sections with their community service partners. We are hopeful this will help with that very tough issue of implementation. We'll see!

Best,

Kathy

Thanks, Chris! I actually have that paper, I just realized - in my "to read" file...uh....pile.  Guess I better read it....

Brenda, I totally understand. I was told years before about the "identified patient." It's an old psychology term for the one person in the family who is the healthiest amidst the dysfunction and denial of the rest of the family. They are the one who seeks help. I'm sorry you are all alone in your family. It IS devastating. Time certainly does not heal all wounds. Not in such a sick group/family climate. And then we as survivors sometimes reach out to our community for help or in the role of an advocate and get retraumatized, yet again. It's not a good scene to put it mildly. Take breaks from the "fight" when you can to recharge your battery and try and establish a support system. Just please know you are not alone.

No, Louise, I won't be able to make it, unfortunately. I'll be on a reporting trip in Central CA that week. 

btw, you might want to tell the people who attend your workshop that the Academy on Violence and Abuse has gathered a group of physicians & researchers to put together a white paper for health care practitioners about ACEs. It's meant to provide information to physicians about ACEs and guide them on what to do when a patient asks them about ACEs. It'll be about 15 very short (two-page) chapters, written in a medical journal style with which they're familiar, with footnotes and useful links. They're hoping to post it on the AVA site in a few weeks.   

Cheers, J.

Thanks, Jane!

I'll forward this to Dr. Felitti, He'll be jazzed!

Sorry we won't see you. :(

Lou

Jane,

I am very interested in this paper. Will it be posted on the ACEs connection site as well? Or should I just keep checking the AVA site?

Best regards,

Kathy

Dr. Felitti,

Have you ever used or heard of a primary care practice using the ACE score as a screen? I'm working with a group in Vermont drafting screening guidelines for primary care. We're concerned about the length of any tool we propose, since the practices are so busy and a long screen tends to provoke a reaction of "I don't have time for that."

We're considering suggesting instead that practices offer the ACE score calculator to patients. Our thinking has been that the patient could be invited to fill out the calculator but not necessarily return the sheet to the nurse/doctor - instead, they would only be asked their score, as in indicator of the "trauma-load."

All patients indicating any past trauma would be offered an appointment with a therapist. We haven't gotten beyond that point yet!

We are strongly encouraged, of course, to be offering only evidence-based tools, so I'm wondering if there are any studies of the ACE score (I haven't found any), or any other materials supporting its use.

ALso, do you have an opinion on this idea?

Best regards,

Kathy Hentcy

So tragic.  I think you are absolutely correct: most physicians are simply not comfortable hearing this.  There are two plausible reasons:

a) Avoidance of possible triggers that may provoke unconscious (or even conscious) and non-integrated emotions relating to their own traumas or vicarious traumas

b) From my highly limited experience as medical student, physicians are trained to always ask, "what am I going to do with this information?" and "how does it affect treatment?"  - so the obvious concern is that we are not taught anything about Trauma-Informed Practice and we are not taught about ACEs...

Dr. Felitti has addressed this at Kaiser in his questionnaire (which he spoke of on this thread) in a section of his book chapter in "The Hidden Epidemic: The Impact of Early Life Trauma on Health and Disease" edited by Lanius & Vermetten. 

In his chapter, titled "The relationship of Adverse Childhood Experiences to Adult Medical Disease, Psychiatric Disorders, and Sexual Behavior: Implications for Healthcare," he speaks about the integration of the ACE Study findings intoo clinical practice through expansion of the Review of Systems and Past Medical History sections of an AT HOME questionnaire. The clinician is then trained or, perhaps a better word, prompted to respond in a trauma informed manner. The implications are tremendous! 

As his post indicates that over 440,000 adults completed this questionnaire, so that's a lot of data.  I think that this incontrovertible evidence truly highlights the need for a new paradigm in medical and health provider education.  Perhaps more insight can be garnered from this and translated on a larger scale?  I think so!

It's a brilliant read! 

sam

You can also check out how his Health Appraisal system worked in this post:

How we integrated ACE screening into the Health Appraisal Center at Kaiser Permanente in San Diego

-- J.