Imagine you are six years old in 1956. At a dentist appointment, you learn that you have a cavity, and the tooth must be pulled. Your nerves get the better of you, and the tears begin. The dentist slaps your face and admonishes you to stop crying. Unfortunately, this is a real patient experience. Intellectually, this patient knows that she will never again have such an experience. Yet regarding her fear of dentists, she says, “You can’t reason this away.”
To many surgeons, “trauma” connotes physical injury, but considering a broader definition could improve our practice. Trauma comes from any past adverse experiences, such as child abuse, racism, homophobia, terrorism, and more. As seen in the opening anecdote, health care itself can be traumatic. Medical trauma extends beyond obvious events like this example. Microaggressions can take a cumulative toll on a patient’s mental state and their trust in the health care system. For example, a depressingly common experience for transgender patients is encountering clinicians who use incorrect pronouns or make assumptions based on generalizations about trans people.
Trauma-informed care is a concept that is rapidly gaining traction. Trauma-informed care includes “screening and trauma recognition, understanding the health effects of trauma, patient-centered communication and care, emphasis on emotional safety and avoiding triggers, and knowledge of helpful treatment for trauma patients.” The push to adopt trauma-informed strategies has been led by primary care; literature on surgical specialties is sparse. A survey-based study explored physicians’ perspectives on trauma-informed care, in which only 17% of participants were physicians and an even smaller subset were surgeons. There is an effort at Oregon Health Science University to develop a trauma-informed care curriculum for surgical residents; this program appears promising, although it is still in early stages.
Surgeons’ roles are unique because of the invasiveness of our work. Surgery requires the patient to relinquish their bodily autonomy, which can be challenging for patients with a physical abuse history. The patient embarks on surgery with a knowledge that things will happen to their body of which they are not conscious, let alone in control. Why, then, are surgical fields slow to adopt trauma-informed care? Perhaps it is because we so often defer issues other than the patient’s chief concern to another clinician. “Talk to your primary care doctor about that” is a common phrase in any surgical specialty clinic. Probing mental health and past traumatic experiences is outside both the training of surgeons and the scope of their practice, as noted recently. However, I believe that an effort to deliver trauma-informed care can improve surgeon-patient relationships by fostering a trusting environment. How would it look to take a trauma-informed perspective as a surgeon?
Asking for the patient’s preferences around the physical exam could be easily incorporated into visits. This is often taught in medical schools, but quickly forgotten once time constraints, repetition, and desensitization set in. One patient with a vagal paraganglioma recalls an appointment with a surgeon who noticed that palpating her tumor caused her to cough. She recalls the surgeon remarking coldly on how “interesting” this exam finding was. Without asking her, he invited multiple trainees to repeat the exam. The patient contrasts this experience with one involving a different surgeon, who asked for permission to palpate her neck up front. He explained the rationale for his exam and summarized his observations along the way. Her feelings of ease with this surgeon define this visit as one of the best of the many encounters that she has had with the health care system throughout the long course of her illness. “That was years ago and I remember it like it was yesterday,” she says. Frank discussions of surgical procedure, including draping to maximize modesty and expectations for postoperative wounds and bodily sensations, could also be helpful. Finally, many patients struggle to find trauma-informed clinicians in other specialties. A surprising number of patients make it to surgical specialty clinics without having a PCP, let alone specialists for their comorbidities. As surgeons, it would behoove us to keep a running list of trauma-informed colleagues so that we can refer wisely.
In the hopes of improving my patients’ experiences, I chatted with a PCP about trauma-informed care. I found myself enthusiastically agreeing until he said, “We must be kind to ourselves. We cannot address patients’ trauma until we address our own.”
“That doesn’t seem right; we’re not traumatized,” I thought. Yet he argued that the nature of our work is itself traumatic. The literature on physician well-being supports his claims. A 2021 cohort study defined the following as trauma: “patient critical illness and death, serious medical errors and complications, treating people exposed to natural and human-generated disasters, workplace violence, and hazardous exposures (e.g., the COVID-19 pandemic).” We seem to be deeply affected by these experiences. Of 1,134 interns, 56% reported exposure to traumatic experiences at work, with 19% of these screening positive for PTSD. Studies in surgical residents are especially alarming. A cross-sectional study of 582 U.S. surgical residents found that 22% — three times the general population — screened positive for PTSD. Things are even more grim for surgical residents in marginalized groups. For example, LGBTQ+ general surgery residents are more likely to undergo workplace abuse. Though the culture is changing, in many surgical specialties, there is still pressure to appear unperturbed by trauma. While remaining composed under pressure is an essential skill for any physician, we should be encouraged to process trauma off the clock.
As my acquaintance pointed out, addressing our own trauma is crucial for quality patient care. There is a statistically significant link between physician trauma and burnout, which can harm professionalism, patient safety, and patient satisfaction. In recognizing the signs of trauma within ourselves and treating ourselves with empathy, we may be able to better extend that perceptiveness and empathy to our patients.
Do you provide trauma-informed care to your patients? Share in the comments.
Sophia Uddin, MD, PhD, is a fourth-year otolaryngology resident at University of Maryland in Baltimore. She plans a career in general otolaryngology, with research interests in hearing restoration and sleep.
Illustration by Diana Connolly
