Kathy and Heather,
I’m going to put down some of my random thoughts to try to respond to the questions that you have raised.
Realize that most physicians still do not see this as a core piece of primary care. They still see this as a social issue, criminal justice issue, et cetera. In order for them to have any chance of incorporating this into their practice, they must see this is as truly a healthcare issue. In addition, it is hard for physicians who are already in practice to make a change in the way they address patient care. This is not like prescribing a new pill. The physician may come to a conference, they may believe what is being said, but to go back to their offices and incorporate this understanding as a new approach in their practice is not likely. As was detailed in the IOM report of 2001 (Confronting Chronic Neglect), if there is no infrastructure in the practice setting to support doing this work then it is unlikely to be carried out.
So, in order to make this happen remember to first of all try to have physicians teach physicians. Make sure that you focus on the health physiology, microbiology, neuro- chemistry, brain science, etc. to help make the point that this is a healthcare issue. And thirdly, provide the support components to help them carry this out in their office. This would include questionnaires that can be used, documentation methods that can be used, specific strategies to respond to acknowledgment of violence and abuse issues, etc.
Quite a few years ago, we created a paper questionnaire in our ER to better identify women in abusive relationships. It was a single piece of paper, folded in thirds, with a question about the health of their relationship. We avoided words like abuse, forced, etc. There were three categories from which you could choose. This wasn’t a Yes/No questionnaire. When we started using it, our identification rate for IPV went from 2-3 per month to 2-3 per day. However, the program was not sustained.
In addition, I felt that this screening tool met the needs of the requirement to screen, but it did not meet the needs of the patients who presented with hundreds of various complaints that reflected any number of lifetime experiences of adversity. Over the years, I heard thousands of stories of adversity - not because I used some standard screening tool, but because I asked the patients to tell me their stories. I learned how to guide them in their narrative so that the relationship of their adverse experiences to their state of health became apparent. Some of the interview techniques follow:
For current life stresses, I might say any of the following:
- We all experience stress in our lives, can you tell me where your stress is coming from?
- Is your marriage/relationship everything you hoped it would be?
- On a scale of 1-10, how would you rate your relationship?
- If not a 10, what’s missing? What do you wish would be different?
- Can you count on your partner to help you/take care of you/give you a break with the kids, etc?
- When you get up in the morning, do you look forward to going to work?
When I saw patients who had complaints or a history of problems that were consistent or characteristic of people who had significant adversity, I might say or ask:
- Life has been more of a struggle for you than most people, hasn’t it?
- I suspect that you have had things happen to you that shouldn’t have, that you wish you could forget or erase from your past. It wasn't your fault that those things happened to you.
- When I see patients with problems similar to yours, I often find that there is a significant history of bad things/harm/struggle/a very challenging childhood, etc., that contributes to the way you feel. I’ll explain why that happens in a moment, but, can you tell me a little about those experiences?
- In the past we used to talk about stress causing illness without any real proof. But, now, science has shown us much more clearly how stress affects our health. In fact, there is a rapidly growing field of research that very clearly shows changes to the brain itself, changes to our hormones and neurological function as a result of growing up or living in a chronically high stress environment. One of the most important research studies was around something we call ACEs. This refers to adverse childhood experiences. There are about ten categories that were used in the study. I’ll list them for you, but these are not meant to be inclusive of all the kinds of experiences people have. As I go through the list, I’d like you to make a mental note of about how many of these categories apply to you. Then I’ll show you what the research says about the risks for various conditions.
When I saw parents with kids who looked like they were struggling, questions might include:
- Do you ever feel like you are at the end of your rope?
- Have you had time to focus on your relationship with your partner?
- If not, how has having children impacted your relationship?
- Are you afraid?
- How has this affected the sexual part of your relationship? Are you having sex just to keep peace in your relationship? No one should have to do that.
- What kind of support system do you have?
- We are only human. When we are faced with challenges like this, many people would find this difficult. We can feel overwhelmed. Do you find yourself using alcohol, street drugs, etc., to help you cope or get through the day? (If so), I’m not surprised. It makes sense that you might do that. Would you be willing to explore healthier ways of helping you to cope? I suspect that you would feel better about yourself if you could find a way to deal with all of this without turning to alcohol.
- If your relationship is starting to fray, do you find that you are fighting a lot? Physically or just verbally?
Anyway, I hope you get the idea. There is never judgment, condescension, or questioning of the validity of what the patient says.
I have written about a dozen or more scripted scenarios for various health professionals to practice saying the words without the threat of “role-playing.” Generally, these scripts are read out-loud in small groups where each person gets to play both the patient and the provider by the end of the session. By putting the words in their mouths and practicing listening to the response it is often anxiety-reducing when it comes to the real thing.
With regard to the question about “What hooks a doctor to get them to start paying attention,” it’s not a simple answer. For me, it was the stories that were revealed. In the mid 1980’s, a physician friend doing a fellowship in chronic pain told me that most of the patients they saw with chronic daily headaches had a history of child sexual abuse. I was aghast. A couple of weeks later I saw a women in her forties with chronic belly pain. I very clumsily asked her if there was any chance that she might have been abused, sexually, when she was a child? Her answer was, “Well, yes, I was. But, I’ve never told anybody before.” I decided that if this was the answer the first time I ever asked, then I had an obligation to explore these issues more routinely. Thousands of stories later, there is no question in my mind about the role adversity, violence, abuse, plays in our health.
The AMA Code of Medical Ethics has some robust language around the responsibility of physicians to address violence and abuse issues in their patients. This happened because of the work done by the AMA’s National Advisory Council on Violence and Abuse. That Council worked diligently with the Council on Ethics and Judicial Affairs to get the changes made from what was a very weak statement that was vague and short.
Good luck with your programs. Think creatively. Think of what will be good for the patient, not just for an issue. Look at making change by understanding how each professional works rather than just pushing a policy that doesn’t feel right to many and may end up doing more harm than good. Look at the whole infrastructure and make sure it supports what you are teaching/training. The best way for professionals to incorporate dealing with life adversity into practice, is to start during their academic years. Going out into practice feeling comfort in addressing these issues, knowing how to ask, respond, reassure, support, and knowing what resources are available are key to making a community wide change.
Dave McCollum
