Dr. Arnd Herz, a self-described champion for ACEs science, would like nothing more than to witness a greater appreciation of how widespread adverse childhood experiences are. Herz, a pediatrician and director of Medi-Cal Strategy for the Greater Southern Alameda Area for Kaiser Permanente Northern California, would also like to encourage more people in health care to engage in a trauma-informed care approach, a change in practice that he says not only benefits patients, but also health care providers and their staff.
“It makes so much sense,” say Herz. “This is why I went into medicine. I don’t want to just click off diagnoses, but create relationships and help people by understanding them better, and trauma-informed care is just a way to bring compassion back into the care that we do.”
For the uninitiated, a trauma-informed approach includes an awareness that adverse childhood experiences (ACEs) are common, knowing how to recognize the signs and symptoms of trauma, creating a safe environment where the focus is on “What happened to you?” rather than “What’s wrong with you?”, engaging trauma survivors as equal decision-makers in their care, and offering patients referrals to supportive services as needed, according to a report by the Substance Abuse and Mental Health Services Administration and a primer by the Center for Health Care Strategies.
In practice, Herz describes how clinicians use a trauma-informed approach to forge closer ties with patients and at the same time discover how ACEs may lurk beneath the surface of a health condition.
“I see so many children who really struggle with obesity at a young age,” explains Herz, who is based at Kaiser Permanente in Hayward, Calif., which is testing ACEs screening of children from 12 months through 5 years old in a three-year pilot study that began in 2016. He says that he sees many patients whose weight and height are on par for a number of years and then suddenly veer off course as a child begins gaining weight. “I’ll ask ‘What happened?’, and sometimes it’s that the grandmother has moved in and is overfeeding the child,” explains Herz. But often there’s another explanation.
“I pointed to the growth curve and asked ‘What happened two and a half years ago?’ And the mom said, ‘Dad came back from jail and is living with us,’” reports Herz as he cites the case of one patient. And he didn’t stop there — he wanted to find out how the mom and the child experienced the father’s return. “And I looked at her and said, ‘So, it’s been stressful?’ And she said yes.”
“And rather than talking to her about removing the sodas, and exercising more and removing the junk food,” continues Herz, “I talked to her about the stress and how can we make things feel better, because the weight gain was in response to stress.” Herz made sure they were safe and when the mother expressed interest, helped her and the child link up with a psychologist for additional support.
“If I just talked about cutting out soda and junk food, it wouldn’t have any effect, and it’s very satisfying as a physician to feel like I really understand what’s going on in this family.”
Herz is well aware that part of his own comfort in asking those kinds of question is also because he knows his patients won’t be stranded without help; there are social workers and therapists in their pediatric clinic who can take the conversation further.
The question of comfort in asking patients deeper questions brings up another significant point for Herz: What are some ways that the practice of engaging with patients using a trauma-informed care approach could have a broader reach?
Herz has made a case for doing so in an essay he wrote entitled Compassion-infused Care.
Why the use of the term “compassion-infused care”? Herz suggests that the term may have greater appeal to a wider swath of health care providers.
“What struck me early on was that most people who talk about trauma-Informed care do it in public health clinics that serve Medi-Cal [Medicaid] patients, the very extremes, the really traumatized populations. And I thought in many ways [the term] trauma-informed care carries stigma,” said Herz. “I haven’t had people say they don’t want to do it. It’s just my hunch.”
In the essay, Herz notes how trauma-informed approaches to care have been implemented throughout such organizations, including San Francisco’s Department of Public Health and Montefiore Medical Center in New York.
Herz also suggests that the concept of compassion-infused care more clearly captures an important part of what makes practicing medicine fulfilling to clinicians and thus might better emphasize how a trauma-informed care approach serves as an antidote to physician burnout, a problem experienced by some 42 percent of 15,000 physicians surveyed, according to a 2018 Medscape report.
“In health care these days, particularly in primary care, it’s very easy to get into the rhythm of ok, I have to see a patient every 15 minutes, I have to come up with specific codes for the billing piece of it. I have to come up with the right diagnosis and give the patient something so they feel satisfied at the end of the visit, and complete the computer coding and move on to the next patient,” explains Herz. “To me that’s at the core of physician burnout, that it becomes routine, and move on and it’s a high stress environment.”
With the right knowledge, tools and resources for dealing with trauma, explains Herz, trauma-informed care adds depth to relationships with patients. And by highlighting compassion, he says, “What I’m hoping is that will become a concept that is even more mainstream, that large health care organizations, including my own, embrace — that we want to become a compassion-infused organization.”
“I may be wrong, but I’m thinking it’s easier to say: ‘We’re going to become a compassion-infused organization rather than a trauma-informed organization’. One is a more positive image that we’re going to increase our compassion. The other is a more threatening image that we have a more traumatized population that we take care of.”