March 28, 2018

From Rolf Nesse, MD

Gaining Knowledge

Learning about social and economic predictors of health has been embedded into my medical training for my entire career. In the 1970’s in Medical School at the University of Washington, I was taught the Holmes-Rahe Life Stress Inventory, by Dr Holmes himself. We used that scale to predict the near-time health risk of common life events. Later, I learned from Dr. Joel Seres, a pain physician from Portland, that child abuse of boys lead to a very high risk of chronic back pain and taught it was a primary cause.

Through the years, additional pieces of information added to my understandings. Poverty and income inequality proved more dangerous to health than smoking, drinking, and sedentary living. But, in spite of all this accumulating data, the practice of preventive medicine remained focused on vaccines, mammograms, cholesterol testing, and the like. Indeed, I was graded on how well I got all this important work done. The institutions of medicine wrongly remained locked into the doctor’s office box view of health.

In my final years of practice, I was taught by a pediatric colleague, who was implementing trauma-informed practices into the schools and law enforcement systems in Spokane County, Washington. I was very impressed with what she was doing and studied the Adverse Childhood Experiences (ACEs) literature which filled in a lot of gaps in my understanding of what I had been seeing in my patients all my career. I learned all of this just in time to retire!

Applying Knowledge

Returning to Oregon, I was introduced to Trauma Informed Oregon, attended some trainings, and learned even more. Now I do a little teaching of medical students at Oregon Health and Science University, and incorporate my new understandings into my sessions where it is appropriate. I have been doing volunteer teaching of two types.

  • I proctor and grade student presentations of cases they have seen in clinic. They do research on some aspect of the case and present it to their peers and me. After they are done, I add clinical insights into their topics. If there is a significant component of socioeconomic influence or trauma likely from the presentation, I will explain how that might influence the approach to the patient. My time for this is brief, thus not comprehensive.
  • I have taught first year students physical exam and findings in different disease states as well as some sessions on clinical statistics. We discuss aspects of how you deal with body space and patient comfort and consent. In the stats part, when assessing the quality of a research design, I reminded students of the large socioeconomic confounders often left out of clinical research. Also, judging if a particular patient matches the research cohort includes knowing if the person has things like a high ACE score.

Incorporating Knowledge

The curriculum (not a part that involves me as a volunteer) does include social and economic influence. Also in their training for clinical interviews, students are taught a style of interaction that is fairly trauma informed, although they may not use that name. I am very pleased to note that most students by the third year are aware of ACEs science, but not yet prepared to use this knowledge effectively. We can only hope that clinical research will advance the skills and abilities for the medical profession to promote health by practicing in trauma-informed ways. Also, medical institutions should acknowledge the limits of conventional prevention strategies and advocate for social and economic changes in public policy.

One observation I have made is that the focus in many presentations of ACEs effects seems to be on the real and devastating effects on girls. That is how I saw ACEs effects in my office as well. Clearly the effects on boys is just as severe, but less easily identified in later life. I would hope we can learn how to better interface with this issue.