April 4, 2018

From Joan Fleishman, PsyD, Behavioral Health Clinical and Research Director, OHSU, Department of Family Medicine

Oregon Health & Science University (OHSU) Family Medicine at Richmond is an urban Federally Qualified Health Center serving over 13,500 patients in southeast Portland, OR. Our clinic is known to care for some of the most vulnerable and underserved populations in the city. Our work on Trauma Informed Care (TIC) began in 2016 when approached by Trauma Informed Oregon to collaborate on adapting standards of TIC practice to healthcare settings and implementing TIC at our clinic. Read the final report about our efforts.

As a leader of this work, I believe that it is our ethical responsibility to practice TIC as healthcare providers. The emotional and physical state in which we provide care matters and we must strive to maintain a compassion stance with our patients.  Science actually backs that up. Research on interpersonal neurobiology, the study of how the brain and body react in relationships with others, suggests that when a care team member is more stressed, that can influence the patient’s physiological state and, with the function of brain activity like mirror neurons, can actually activate the patient too. What this field proposes is that humans can develop similar emotions, thoughts, and behaviors of those whom they are around and interact with. Our work at the clinic has been to integrate these ideas into our workflows from the moment a patient walks in the door to the way we craft clinic policies.

Focusing on the Patient Experience

Maya hated going to the doctor. It wasn’t actually her doctor that she didn’t like. In fact, Dr. Fitzgerald was one of the best doctors she ever had. But Maya had seen a lot of doctors when she was little, and almost always it was when she couldn’t breathe. She could remember the tightness in her chest and throat on the playground as her second grade teacher ran over with her inhaler. She remembered the countless nights in the emergency room doing breathing treatments with her mother by her side. The trips to the emergency room were often triggered by Maya waking up in the middle of the night unable to breathe. Maya had asthma, and unknown to anyone at that time, the apartment her family lived in was making it worse.

Now in her mid-twenties, Maya’s asthma had worsened, landing her in the emergency room again. The bright lights, doctors’ white coats, and beeping of monitors brought a flood of memories; clutching her crying mother’s hand, rubber oxygen masks that pulled on her hair, and that terrifying feeling of gasping for air. Maya left the ER that night knowing she had to return to her doctor to get her breathing under control.

Maya arrived for her appointment in the clinic on time. She stepped into the busy lobby, noticing the large man sleeping in a chair in the corner, the children playing by the water fountain, and the young mother with tears streaking down her face holding her sleeping child.

She approached the front desk and was told her doctor was running late. Her throat tightened and her brow furrowed as she wondered how long she could manage sitting in the busy waiting area.

The front desk staff noticed Maya’s darting eyes and that she seemed stressed. As she checked in Maya for her appointment, she thought about how she could use TIC principles in this interaction. She started with being kind and reassuring.  She noted how busy the waiting area was, offered Maya some water, and then offered for Maya to wait outside on the bench. Maya felt her chest relax and her breathing slow as she walked back outside to wait. As Maya waited outside, another scene was transpiring inside.

Focusing on the Staff Experience

As Dr. Fitzgerald’s schedule got farther behind, Trisha, the medical assistant working with Dr. Fitzgerald started to notice how stressed and on edge she was feeling. She had tossed and turned last night worrying about her grandmother who is on hospice. Today she felt pressure to work quickly, which made her worry about making a mistake. She missed her break in the morning because a colleague called out sick. She felt stressed and on edge.

She imagined what would happen if she just went on, business as usual. Resentful of the situation, her voice would be loud and abrupt when she would go get her patient. Feeling rushed she would walk quickly, leaving her patient several paces behind. She would snap at her to get on the scale and that she needed to get her weight. She is embarrassed about her own weight and knows the feeling of dread around the scale. Her patients actually remind her a lot of herself.

Trisha, made a crucial decision at that moment. She remembered what she learned in her TIC training about how her own history and stress levels could affect how she interacted with her patients. She asked her teammate to cover for her for a few minutes and took care of herself.  She got some water, a snack, took a few moments of quiet, and focused on her breathing. After only a few brief minutes, she was ready to jump back in. Trisha went out to get her next patient.

Maya heard her name and again felt her throat tighten. She knew what was coming. She hadn’t weighed herself in months, maybe years.  She knew the number was not going to be good and felt a wave of uneasiness come over her. But to her surprise the medical assistant asked permission to weigh her, explained why she was asking, and gave choices for how to make the experience more comfortable. This made the experience tolerable and they even shared a laugh together about how uncomfortable the whole thing was.

The medical assistant led Maya into the small, cramped exam room and waited for the door to be fully closed to ask her what had brought her in. Despite the medical assistant’s calm and purposeful manner, Maya’s heart was racing. She tapped her foot on the old linoleum floor and stared across the room at a wall of brochures on different medical problems. Her mind had gone blank, remembering all those times in the emergency room gasping for air.  “I’m here for my asthma I guess,” She said.  “Oh, and I have been getting headaches too.” The medical assistant reassured her that the doctor would do everything she could to assist her today and asked her if she preferred the door open or closed while she waited. This was the first time she had been asked this. She thought maybe leaving the door open would give her more breathing room.

Dr. Fitzgerald entered the room with a smile.  Her soft eyes met Maya’s and she sat down across from her. The doctor offered her hand in a greeting, paused, planted her feet on the ground, took an intentional deep breath, and said, “Good morning, Maya, it’s so good to see you. I saw that you were in the emergency room recently. Before you tell me about that, I notice you seem anxious today. Can we talk about how you are feeling right now?” Maya had been holding her breath and as Dr. Fitzgerald calmly started to ask her about what was going on her breathing deepened and slowed. Maya started to relax.

Benefiting Both Patients and Staff

This story exemplifies trauma informed practice in a healthcare setting and how it can benefit both patients and staff. Although fictional, Maya, Trisha, and Dr. Fitzgerald are based on my many observations in the clinic of staff and patient interactions that have become commonplace since implementing TIC.

Medical settings can be challenging for patients and staff for many reasons and there are many opportunities to foster a sense of safety, empower people by giving them choices, and emphasize their strengths.

By training staff and providers to realize the prevalence and impact of trauma, how to recognize the effect and associated behaviors of someone under stress, respond with appropriate interventions, and resist re-traumatization, we have equipped our workforce with powerful knowledge and tools to foster resilience, prevent burnout, and better meet the needs of our patients.  Before knowing about the Four R’s of TIC (Realizes, Recognizes, Responds, and Resist re-traumatization) and TIC Principles, it is likely that staff like Trisha gave little thought to how they entered the exam room, their own activation level throughout the day, and how powerful offering choices can be.

With support and consultation from Trauma Informed Oregon we began by using the Standards of Practice for Trauma Informed Care – Healthcare Settings  to create a framework for our efforts in transforming our practice to be more trauma informed. As we embarked on this journey to provide TIC to patients we focused first on our workforce and areas they identified as needing improvement

Why start with staff? The Adverse Childhood Experiences study (ACEs) helped us understand the high prevalence of trauma in the general population. We know the healthcare workforce is under stress, we absorb the trauma of our patients, we have trauma survivors among us, and our organizational systems can feel oppressive. And all of this has an impact. This is why we started with cultivating trauma awareness, safety, choice and empowerment in our workplace and workforce.

Implementing TIC in a healthcare setting has its unique challenges. We have encountered tension between the clinical quality measures, such as recording a patient’s weight, and trauma informed practice. Medicine often has conflicting pressures including clinical quality metrics that require careful thought and consideration in regards to how to make these practices trauma informed. We are working on clinical processes such as this to empower our staff to raise awareness, create safety, and give patients choices.

Once awareness of TIC is raised on an organizational level, staff will start to recognize areas for improvement. It is important to create a safe space to raise these concerns and a process of how to respond to what is raised. A TIC workgroup can serve as this venue in a health center. The majority of the first phase of our work on TIC has been to train and empower our staff to implement the principles and create safety for their colleagues and patients alike.

As we continue this work we hope to address questions like, how do we create a workplace that allows for sustaining a compassion stance? How do we foster resilience and find ways to do our work that reduce the opportunity for activation and re-traumatization?