Nandi and Puranam had discovered their mutual interest several weeks before that workshop, as they discussed one of their classes in the anatomy lab locker room. “In our Health Systems Science course, we were learning about a lot of really difficult topics like elder abuse, child abuse, intimate partner violence,” Nandi says. She felt the course often didn’t acknowledge that these issues may have affected people in the room. “Providers and health practitioners are also humans who are just as susceptible to experiencing all these things,” she says.
Puranam agreed, and they began to look for more places in the first-year curriculum that could better prepare students to care for patients affected by trauma and cope with the widespread phenomenon of vicarious trauma among physicians and trainees. Ultimately they decided a preclinical elective about trauma-informed care would be the most comprehensive way to introduce these concepts, and they asked Elisseou to be their faculty adviser as they developed the course.
While trauma often conjures images of extreme violence and physical injury, the range of events that can trigger adverse biological reactions and avoidance behaviors is much broader. A 2013 study published in the Journal of Traumatic Stress defined a traumatic event as one that produced physical injury, one that elicited fear of physical injury or death, or “any [other]extraordinarily stressful event or situation.” Using these criteria, plus follow-up questions to determine the context and severity of any such event, the authors concluded that 89.7 percent of participants had experienced at least one trauma. However, fewer than 10 percent of these participants showed signs of PTSD, which is a hurdle that Karen Johnson, MSW, LCSW, the senior director of Trauma-Informed Services at the National Council for Behavioral Health, sees in medical practice. “Only looking for diagnos
able PTSD or another mental illness is a mistake,” Johnson says. “Trauma manifests itself in many different ways.”
Evidence points to an association between adverse childhood events and poor health outcomes later in life. In a survey-based study of 9,500 respondents from a single HMO group, published in the American Journal of Preventative Medicine in 1998, people exposed to traumatic events during childhood were found to have a tremendously increased risk for smoking, alcoholism, drug abuse, depression, suicide attempts, sexually transmitted disease, obesity, heart disease, cancer, lung disease, liver disease, and fractures.
So-called “high-risk behaviors” and their associated negative health effects only tell half of the story, however. Fears of re-traumatization during medical encounters, such as the physical exam, can cause traumatized patients to avoid the health care system altogether, compounding the effects of their physical ailments. Empowering patients by reestablishing feelings of safety, autonomy, and trust could help them overcome these fears. “When you experience something traumatic, you lose your sense of control over what’s happening,” Nandi says. Ideally, a trauma-informed approach restores these feelings to the patient in the medical environment, mitigating the cause of some of these negative health outcomes.