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How Physicians Can Bring Trauma-Informed Care to Their Patients with Dr. Sadie Elisseou

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Dr. Sadie Elisseou and Jill Farmer discuss how physicians can bring trauma-informed care to their patients.

“There’s no organ called ‘the mental’. This is your brain’s health. It’s an actual organ and it happens to be the most important organ in the body. And so this is very real; it’s not made up. When people are presenting with symptoms of PTSD, they’re not going bonkers, they’re not crazy. This is very concrete, very described, and fortunately, there are strategies for healing.”

– Dr. Sadie Elisseou, MD

Nationally recognized health expert Dr. Sadie Elisseou joins our conversation today on DocWorking: The Whole Physician Podcast, to discuss trauma informed care. Master Certified Coach Jill Farmer talks with Dr. Elisseou about how she developed an award-winning curriculum on ‘trauma-informed physical examination’ that is now taught in medical schools across the United States. Her inspiring story serves as an example of how we as physicians can respond to our patient’s needs in order to strengthen relationships, give aid to others, and create a more fulfilling practice of medicine. 

Resources mentioned in the podcast: 

A Novel, Trauma-Informed Physical Examination Curriculum for First-Year Medical Students– Curriculum on Trauma-Informed Physical Examinations, MedEdPORTAL, by Dr. Sadie Elisseou

Books mentioned in the podcast:

What Happened to You?: Conversations on Trauma, Resilience, and Healing by Bruce D. Perry and Oprah Winfrey

Sadie Elisseou, MD is a primary care physician in the Boston VA healthcare system, a Clinical Instructor of Medicine at Harvard Medical School and Adjunct Instructor of Medicine at Boston University School of Medicine, and a nationally recognized expert in the field of trauma-informed care (TIC), an organizational framework for supporting survivors of various forms of trauma. Dr. Elisseou’s award-winning curriculum on ‘trauma-informed physical examination’ is now being taught at medical schools and healthcare institutions across the country. Last year Dr. Elisseou worked with VA colleagues to publish a framework for trauma-informed telehealth. Dr. Elisseou is the co-founder of the Veterans Health Association TIC Collaborative and a member of the Trauma Informed Health Care, Education and Research (TIHCHER) collaborative and the Harvard Medical School TIC Steering Committee. She enjoys building platforms for educating healthcare professionals in trauma-informed practices.

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Podcast produced by: Mara Heppard

Please enjoy the full transcript below

 

Sadie: There’s no organ called ‘the mental’. This is your brain’s health. It’s an actual organ and it happens to be the most important organ in the body. And so, this is very real. It’s not made up. When people are presenting with symptoms of PTSD, they’re not going bonkers, they’re not crazy. This is very concrete. It’s well described. And fortunately, there are strategies for healing.

[DocWorking theme]

Jill: Hello, and welcome to DocWorking: The Whole Physician Podcast. I’m Jill Farmer, one of the cohosts of the podcast and lead coach at DocWorking. And as always, we’re brought to you by DocWorking THRIVE, where we provide coaching tools to help you live your best life, as well as peer support by other physicians. Check us out at docworking.com and take the burnout quiz today. 

You guys are in for a treat, a really fascinating conversation by somebody who’s been on the forefront of something that I think many physicians are going to be wanting to be on the forefront of as we move forward. 

Dr. Sadie Elisseou is a primary care physician in the Boston VA Health Care System, a clinical instructor of medicine at Harvard Medical School, and adjunct instructor of medicine at Boston University School of Medicine. She is also a nationally recognized expert in the field of Trauma-Informed Care, TIC, an organizational framework for supporting survivors of various forms of trauma. 

Her work has created an award-winning curriculum on Trauma-Informed Physician Examination and it’s now being taught at medical schools and healthcare institutions across the country. Sadie, thank you so much for being with us to have a conversation about Trauma-Informed Care for physicians and how they can incorporate it into their healing work with patients.

Sadie: Of course, it’s absolutely a joy to be here today. Thank you so much.

Jill: So, take us back to the beginning. When did you first become aware that Trauma-Informed Care was something that you needed to be thinking about as a practicing physician in the VA Medical System.

Sadie: Back now, eight years ago, is when I completed my training. I decided to get a job at the VA. I work for the Veterans Administration. I’m currently a PCP in the Boston VA Healthcare System. And as I was examining my trauma-exposed veteran patients I realized that there were things I was doing unintentionally that were making my patients visibly uncomfortable. I remember distinctly an episode where I swung my stethoscope off my neck as I always do to start the cardiac exam and the patient jumped. I remember approaching someone to start the thyroid exam and they stammered back. I thought, “My goodness, what am I doing to harm patients?” Because first, do no harm is what we’ve all decided to do. 

I started adjusting my speech, adjusting the way I stood, where I stood, how I behaved in the room, simply in an effort to set patients at ease. I had no other motive in mind. I wanted people to feel cared for and safe. I started teaching those strategies to medical students. And one day, a student asked me, “Dr. Elisseou, can you tell me more about your trauma-informed techniques?” I honestly thought she made that up on the spot. I was like, “What are you talking about?” She told me that, “No, this is really a well-established framework for supporting people who’ve experienced trauma. It can be applied universally as a means of building resilience.” And from that point on, I was completely hooked. I swear, I was in my office for a month doing nothing but reading whatever was published online about Trauma-Informed Care and I developed a formal framework for a Trauma-Informed Physical Exam.

In collaboration with the medical students, we were able to implement that as standard curriculum for first-years. At the time, I happened to be course leader for doctoring at Brown. And so, that’s what we did. We studied it, we published it, won an award for it, and now, it’s being taught at medical schools across the country. So, that’s how this happened. It was really inspired by veteran patients and medical students.

Jill: I think it can make sense for a lot of people listening that somebody who had been in combat, a veteran, would have signs of PTSD in that experience. And so, it makes sense that sudden movements and things like that might elicit a response. But this application is not just for veterans or combat veterans, is it?

Sadie: No, it’s not. I think one thing that’s unfortunate about how we use the word trauma is that traditionally, when we hear that word, we think of perhaps a gunshot wound or someone getting stabbed. We think about the trauma bay in the ER. We don’t think of it more expansively as psychological trauma, sexual trauma, transgenerational trauma in terms of racism, and slavery, and war. And we also unfortunately think of trauma as it relates to our patients, It’s something that only they undergo, right?

I like to refer back to the famous ACE study. A-C-E stands for adverse childhood experiences. This was a giant study that took place in the 90s and it showed that over half of the US population has at least one ACE in their past before the age of 18 in the realms of neglect, or abuse, or household dysfunction. Recent research has shown that rates of ACEs in the healthcare professional population mirror the ACEs in the general population. So, this is not something that just belongs to patients. This belongs to our common shared human experience.

Jill: Beautifully said. We’ve had more than one expert on the podcast to talk about the fact that medical education, the grueling nature of medical education, and for lack of a better word, inhumanity often and care for the wellbeing of medical students actually has been known to impose trauma on [laughs] medical professionals. Now, some say, it’s a lowercase ‘t.’ Not the capital T. There’re all kinds of conversations we’ve had about that. But I think it is something that is just really important to normalize. I love Oprah’s book from the last couple of years. 

Sadie: Yes, Bruce Perry.

Jill: It really helps normalize the fact that we all have had these experiences that essentially left an imprint on both our psyches and our nervous systems. And the good news is, we’re not broken, we’re not scarred, we’re not ruined, no matter what level anyone is on that trauma spectrum. The other news, I wouldn’t say, it’s the bad news, is that at some point in order to heal from that, we have to recognize that we have these things that can trigger us, or we get dysregulated, and learning how to regulate through that. 

Sadie: What that actually reminds me of is something that’s really growing in an exciting way across medical education. There was an article published recently in the Journal of Academic Medicine about time trauma-informed medical education. It’s about both the content of learning about trauma and healing, as well as the context of how we actually learn in a safe space. One example that comes to mind very fresh for me is, I was in the course leader’s office at Brown for our doctrine curriculum and a medical student came in, wanted to speak with us privately and said, “I know we’re going to be practicing blood pressure today. Is it okay, if I keep my sleeve rolled down? There’s something that I don’t want my friends to see.” 

And so, even as we are in medical education space, even as we are learning, we have the potential to be exposed to stress, to discomfort, to trauma, to re-traumatization. It is our responsibility to make sure that our learners are in a place where they feel physically and psychologically safe and empowered.

Jill: And so, would you say, being physically and psychologically safe and empowered is the goal of what you have created in terms of the protocol for physicians performing trauma-informed examinations? And you like to talk about doctors also needing to understand where they are on the trauma spectrum, so, it gives some universality and context to the fact that we all might be better if we thought about treating each other with a little more care.

Sadie: Absolutely. And the core principles of this approach are that, number one, healing happens in relationships. And importantly, these are safe collaborative relationships. And so, that’s the point of whatever we construct in a trauma-informed curriculum or trauma-informed organization, the context is that we are doing this together.

Jill: And so is it the kind of thing that, do you see moving forward, physicians using with almost any patient, whether or not they are aware ahead of time that there is, that patient is likely to become dysregulated or have a trauma response to some of the things that happened in the course of a normal examination?

Sadie: Yes, outstanding question. The idea is that this is a universal precaution. Just like hand washing, we can make the assumption that everybody may be carrying something heavy in their invisible backpack of lived experiences and we have the same approach to all comers. That means that I have the same approach in conversations with my colleagues in nursing or social worker pharmacy, also with the housekeeping staff, also with my boss, also with patients.

Jill: Do you mind giving us a few examples of what happens in an examination when you are employing these Trauma-Informed Care in the way that you perform a regular checkup?

Sadie: Of course. I’ll give you an example of a physical exam maneuver that can be trauma-informed. For generations, physicians have been taught to examine the thyroid by standing directly behind the patient with the fingers fully wrapped around the neck and the thumbs in the back. And so, the patient can’t see where you are, what you’re doing. It also simulates strangulation. And so, this can be unnerving at best. Why not stand instead at the patient’s side within their peripheral vision, have the fingers fully extended on the neck, and let the patient know what you’re about to do and why? If you feel you’re not able to gather accurate data that way, perhaps, you can try an anterior approach. 

The point is, we need to pause and reflect on how our behaviors and language may be affecting the person in front of us. In terms of trauma-informed communication during the exam, I hear the phrase, “for me” constantly throughout the healthcare profession when we give instructions to patients. Unfortunately, it can enhance the power differential that exists between the examiner and the patient, and can even be sexually suggestive and inappropriate. For example, hop on the bed for me, take off your shirt for me, bend over for me, swallow for me. It’s just not a necessary phrase. And so, we can omit it altogether.

Jill: What do you hear, if anything, from patients? Did they notice anything different in the way that you perform the exams in their experience? Either they report to you or that you notice in their demeanor and their experience? What’s been your observation as a professional?

Sadie: Wonderful question. I would say that I’m pretty good at establishing rapport with patients. And I feel that I’ve been thanked for my bedside manner. And all of that comes from, honestly, compassion and being eye to eye and heart to heart with the person in front of me. I do recall an instance where a patient of mine came in with a chief complaint of rectal bleeding. I knew from being this person’s health care professional and I knew from doing trauma screenings that he was an adult survivor of childhood sexual abuse. I knew that I had to do a rectal exam. I didn’t want to do a rectal exam, but he needed one. So, I went through these principles and following my framework for a Trauma-Informed Exam. And at the end, he said, “You were very professional. Thank you. I’m glad that you’re my doctor.”

Jill: What’s your wish, Sadie, based on what you have learned from the experience you have of teaching other physicians and medical professionals, and everyone in healthcare about these ideas, and the meaningful impact it can have on the people you serve? What’s your hope long term for what happens with Trauma-Informed Care?

Sadie: My hope is that this becomes the standard practice across medicine, period. I think that it is often about the nuts and bolts of how you do a specific maneuver in a room, but it is also about cultural transformation and how throughout an organization we can really be kind to one another. This is not a novel thing. However, I do remember when the phrase ‘patient-centered care’ was a new idea in medicine and so, we’re continuing to evolve, it is a really long journey. This work is never over. So, we’re just going to continue seeing this expand.

And interestingly and importantly, Trauma-Informed Care is expanding. It’s expanded to Trauma-Informed Legal Services, Trauma-Informed Social Work for sure. There are entire public-school systems that are becoming trauma-informed. California, I believe just scored a $4 billion grant to address ACEs in their state. And so, this is being demanded by our current society’s focus on equity and justice and it’ll just make sense.

Jill: It really does. I think one of the best things about it is it has us talking about it in public forums. It starts to both demystify and take away some of the stigma around somebody being traumatized or who has PTSD, and it allows us to think in terms of that post-traumatic growth and ways that when we act I think more humanly toward each other. That’s one of the ways that we are able to go from dysregulated to regulated which, regulating dysregulation is really how we heal from trauma. It’s slightly more complicated than that, but not all that much more complicated than that and I think it’s really important for us to have these conversations.

Sadie: It’s unfortunate in terms of the stigma related to mental health that we do call it mental health. I remember hearing from one of my colleagues in the field of trauma that there’s no organ called ‘the mental’. This is your brain’s health. It’s an actual organ and it happens to be the most important organ in the body. And so, this is very real. It’s not made up. When people are presenting with symptoms of PTSD, they’re not going bonkers, they’re not crazy. This is very concrete. It’s well described and fortunately, there are strategies for healing.

Jill: What can someone do if they’re listening to this as a physician or healthcare professional and say, “This all sounds great, but I don’t know anything about it. How am I supposed to learn how to do this correctly?” Because I hear you, my perfectionist physicians listening and healthcare professionals, do I need to go study for 20 years to get this certification to do this? How would you guide people toward becoming more informed about Trauma-Informed Care, so they can incorporate it into their practice in life.

Sadie: There are some very simple resources that I’d be happy to share with you. Additionally, my curriculum on Trauma-Informed Physical Exam is available online. It was published in MedEdPORTAL, which is a forum for publishing MedEd curricula for others to use and adapt for their needs. And I’d say that even if you’re not going to spend time learning all of the specific skills, one thing that has helped me in the past, if I really don’t know what to do next, is that I pause, and I tap into a feeling of compassion, and I know that whatever happens next is going to be okay. I do recall an instance of a pelvic exam with a veteran female patient who had absolutely consented to the exam. She definitely wanted to proceed with it. She knew that it was time for the Pap smear. She’s like, “Let’s get it done.” 

However, as I started to explain things and show her the materials and say, “This is what we’re going to do next.” She was like, “Stop, shut up, I don’t want to hear anything about that. I want you to get it done and get it done fast.” And so, in that instance, being trauma-informed did not mean being highly transparent, and explaining everything, and being highly communicative. It meant shutting up and doing my job quickly and that’s what the patient needed.

Jill: That reminds me of some of the work that’s been done including character strengths, and values and action, and understanding that humility is one of the character strengths that makes us feel most connected to each other. It makes other people feel we are seeing and hearing them the most. And it’s often when physicians do the values and action assessment, humility can be one of the lower ones on their more commonly used values and action. 

When I asked Ryan Niemiec, who is a psychologist on the forefront of the positive psychology movement, I said, “Well, how does somebody get more humble speaking for myself as somebody who also has humility very low on the assessment?” And he said, ”Listening. It’s the simplest way. It’s just simply listening and being willing to take in new information as opposed to constantly letting your own computer brain assess how you can be the one in charge, or the expert, or the one who knows everything.” That has changed my life and I think it relates to what you just said.

Sadie: That’s totally, totally so real and I try to implement that when I’m in the exam room, granted there are so many systems barriers that often get in the way, writing notes, and competing interests. I do my best to type the HPI as the patient is sharing, but my body is turned towards them and I’m making frequent eye contact. And a lot of our conversation in real time is about everything that they want to get off their chest and it’s at the end, when we talk about labs, and this is the to-do list, et cetera, et cetera. But I don’t blab on to them about the running dialogue in my own brain about the CBC, ta-ta-ta. It’s about facetime that is meaningful with the patient.

Jill: Fantastic. We will direct you toward the show notes because we have information on how you can learn more about Trauma-Informed Physical Examinations, learn more about the work that Dr. Sadie Elisseou is doing with her VA colleagues to publish a framework for Trauma-Informed Telehealth, in addition to those in-person examinations. It’s important work and Sadie, I really appreciate you taking the time, so beautifully explain it, and hopefully inspire others to learn more about this, so they can incorporate it into their healthcare practices as well.

Sadie: Thank you so much, Jill. It’s an honor. I think it’s important to recognize that trauma’s probably far more prevalent than we have historically accepted it to be. And now is as good a time as ever to dive into these solutions.

Jill: Thanks again for being with us today. And thanks to all of you for listening. I hope you’ll share this with your colleagues, with medical students that you know, folks in residency, as well as those who have been practicing for a long time. I think it’s an important conversation. We need to be having it more and more. Until next time, I’m co-host of DocWorking: The Whole Physician Podcast, Jill Farmer. Thanks so much for being here.

[music]

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