Trauma-Informed Healthcare Approaches: A Guide for Primary Care

Book Title: Trauma-Informed Healthcare Approaches: A Guide for Primary Care

Author: Megan R. Gerber (editor)

Publication Information: Cham, Switzerland, Springer Nature Switzerland AG, 2019, 216 pp., $59.99, paperback

What if nearly three-fourths of our patients had an unrecognized condition that demonstrated a dose-response relationship with ischemic heart disease, cancer, chronic bronchitis, emphysema, liver disease, or fractures and this condition increased the likelihood of metabolic disorders, depression, suicide, and cognitive decline? The competent physician would certainly want to understand that condition. This is the raison d’être for this slim volume on trauma-informed care (TIC); it is about acknowledging the effects of trauma and adverse childhood experiences (ACEs) in our patients’ lives.

Dr Gerber, who teaches at Albany Medical College, has edited an immensely practical and accessible book that describes the effects of trauma on our patients and what needs to be done to build trauma-informed clinical skills. The book also addresses how to build systems that are healing for patients and the health care team members.

The first two chapters comprise the introduction. The brightest gem in the book is chapter two by Drs Kimberg and Wheeler, both primary care physicians. They tell stories of patients they have known, illustrating how to become a trauma-informed physician working in a compassionate system. They also show how the doctor can use calming techniques to avoid burnout. This is such a powerful chapter that, immediately after reading it, I emailed two physician friends to recommend the book.

The second part of the book discusses TIC with specific populations. This section describes how to cultivate cultural humility when working with patients of diverse backgrounds, including Black men, sexual and gender minority patients, and veterans.

The third section of the book covers clinical strategies for developing a trauma-informed primary care setting. Topics in this section are adult primary care, maternity care, pediatric care, and trauma-informed nursing care. The authors’ clinical experience shines through with many practical tips about how to set up the waiting room and train nurses to interact with patients when rooming them, among many other clinical pearls.

As clinicians, we’re often reluctant to broach sensitive topics. However, the authors report that patients are open to being asked about their adverse childhood experiences¹ and even want to discuss their trauma history

…not in all its terrible detail, but in general outlines. Doing this, and identifying how the abuse may have led to maladaptive coping strategies, can be life changing and ensures that patients do not feel responsible for the trauma they have experienced (p. 129)

It’s helpful to think of these skills as a subset of well-honed, patient-centered communication (PCC) skills. That allows us to consider more broadly the benefits that accompany patient-centered communication skills in one’s practice—things like increased patient satisfaction, reduced anxiety, greater trust in the physician, better patient adherence, reduced treatment avoidance by patients, and reduced litigation.² It is likely that these benefits will accrue to physicians using TIC, since it’s based on the same principles as PCC and uses many of the same basic techniques, such as empathic listening.

The authors acknowledge that studies linking TIC per se to better patient outcomes are scarce. However, the field is in its infancy. Since the publication of this book, more studies have been published demonstrating that patients and physicians like the principles of TIC and that physicians feel better equipped to engage in these conversations after receiving training.^3,4 The next step it seems is to build a corpus of research demonstrating that trauma-informed care goes beyond good patient-centered communication skills.

Fortunately, it’s possible to start with small steps in the clinic, and “Chapter 7: Trauma-Informed Adult Primary Care” and “Chapter 11: Helping the Healthcare Team Thrive” provide valuable strategies on how to do this. They describe the use of “universal precautions” for trauma: If we assume patients have had these kinds of experiences, we will be right 60% to75% of the time, and we will be providing compassionate care to all our patients.

This book could be improved with specific guidance on how to train physicians in TIC. I would have appreciated a chapter on setting up a training program within a residency. In searching for guidance, I found mostly studies using curricula that are unavailable to the public. One glowing exception, Schmitz,⁵ includes in the appendix a complete slide deck for training residents in trauma-informed care.

Starting with this book as a guide, family doctors can become instrumental in creating a health care environment comforting to all our patients and especially to those who have experienced trauma. It is a worthy journey, and Gerber’s book shines a light on the path.