Over the past two years, I have written a column for Forbes. On several occasions, I have highlighted the medical consequences of Adverse Childhood Experiences (ACE's) and Intimate Partner Violence (IPV). The data is clear. Both if not recognized and treated produce negative health care outcomes. Both are very prevalent and asking about each should be standard for physicians and medical practice. But both tend to be ignored by clinicians in American health care today. Jane Stevens suggested I write a blog explaining why.
The evidence about the importance of ACE's and IPV are well documented and the health risks have been identified by organizations such as the Center for Disease Control (CDC). Given all of this research data, the powerful scientific evidence and the demonstrated improvement in health that can result from treatment, why do these health problems continue to be overlooked by the medical profession? To answer that question, I researched a book and published it earlier this month -- Mistreated: Why we think we are getting good health care and why we usually are wrong.
I begin the book with a bigger view of the failings of the American health care system, including the hundreds of thousands of people who die annually from failures in prevention and medical errors -- including my father Jack Pearl. In the book I point out the increased frequency of chronic illness that results from ACEs and IPV, and how each additional event multiplies the impact of the others. I reference the findings that if a person has four ACEs, then their life expectancy declines significantly if not addressed. And I label the section "Childhood Trauma: America's Silent Killer."
Of course all of this information and the statistical outcomes are well-known to the readers of ACEs Connection. What is new information, and the focus of much of the book, is the explanation. Mistreated explains the subconscious process in our brains that is responsible for both physicians and patients ignoring these problems and the impact it has on people and their families. Of course, everyone's situation is different, but there is a common threat that ties together the millions of Americans who have suffered these adverse experiences. And it is how context distorts perception and alters behavior.
To understand the neurophysiology, I reviewed the psychological literature on the subject, examined behavioral economics and studied the most recent brain scanning literature. The findings were unexpected. Although I can't do the topic justice in a posting like this, I will provide a brief explanation.
Think back to when you were in college taking your introductory psychology course. You most likely read about a famous research study called the "Stanford Prison Experiment." A professor, Philip Zimbardo advertised for student volunteers and made sure they were psychologically normal. He then randomly assigned half to be wardens and gave each of them aviator sunglasses, and half prison garb with a number, not a name. Within two days the "wardens" saw the "prisoners" as dangerous, and inflicted degrading punishments. And the latter saw the former as sadistic and boarded up the doors. It's not that they thought this way, but it was what they perceived and therefore, how they acted. And recent brain scanning studies that the book describes show the process in action.
The conclusion is that context shapes perception, which alters behavior. Most importantly, if this sequence can produce negative outcomes, why not positive ones as well? Based on this research Mistreated offers a road map for the future. One that is built on four pillars, and holds hope that problems like Adverse Childhood Experiences and Intimate Partner Violence can be recognized, identified and treated early, before the long-term medical problems develop.
The good news is that in organizations like Kaiser Permanente, with dedicated clinical leaders like Dr. Brigid McCaw and the various chiefs' groups in pediatrics, adult and family medicine and behavioral health the context and perception are shifting. As a result, clinicians increasingly are asking all patients about these health care risks, and health interventions are being provided earlier and earlier. The book tells the story of my father and his premature death from a combination of a failure in prevention and a medical error. We can do better than today, and must in the future.
The book was written for "the patient in all of us." If people across the country read Mistreated, I am optimistic that perception will change, and as a result, so will medical practice. I am confident that once that happens, victims of adverse childhood experiences and intimate partner violence will benefit and my father's death will have served a purpose.
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Robert Pearl, MD, is executive director and CEO of The Permanente Medical Group and president and CEO of the Mid-Atlantic Permanente Medical Group. Together these organizations are comprised of over 9,000 physicians and 34,000 staff members. Dr. Pearl is responsible for the health care that is delivered to more than 4 million Kaiser Permanente members in the states of California, Virginia, Maryland and the District of Columbia.
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