Human trafficking survivors and trauma-informed care [PODCAST]

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“As a physician working with human trafficking survivors, I have become accustomed to those with a history of surviving violence. But the patient in question is in my general primary care practice. This should highlight to care providers that there may be many more patients out there who have been exposed to trauma in their past, and we need to take this into account. One way to be inclusive is to incorporate the substance abuse and mental health services administration principles of trauma-informed care into practice.”

Andrea Reilly is an internal medicine-pediatrics physician.

She shares her story and discusses her KevinMD article, “The challenge of trauma-informed care in the age of COVID.”

This episode is sponsored by The Nuance Dragon Ambient eXperience (DAX). The Nuance DAX solution makes it possible to forget the tech-toggling and reduces documentation burdens no matter how or where care is being provided. 

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show we have Andrea Reilly. She is an internal medicine-pediatrics physician, and she wrote the KevinMD article “The challenge of trauma-informed care in the age of COVID.” Andrea, welcome to the show.

Andrea Reilly: Thank you, Kevin.

Kevin Pho: So we’ll get into your article in a little bit, but first off, can you share your story and your journey to where you are today?

Andrea Reilly: Yes, thank you. So I’m pleased to be both an internist and a pediatrician. I trained in what’s called med-peds and have enjoyed practicing primary care. But then about five years ago, I was given the opportunity to work in a primary care clinic for survivors of human trafficking, and it’s there that I became aware of trauma-informed care.

Kevin Pho: Tell me about some of your experiences, about what it’s like to work in that setting.

Andrea Reilly: So it’s very humbling, Kevin. It really is remarkably challenging at first to learn about how horrific human beings can be to one another. But I’d say the flip side of that, and really the beauty of what I’ve learned, is how resilient human nature is. And so it has really been such a gift for me to have this opportunity.

Kevin Pho: We’re going to talk about your KevinMD article in a little bit, but first off, can you share with the audience a little bit about what trauma-informed care is?

Andrea Reilly: Trauma-informed care is a way to have what we often call patient-centered care. So you’re involving the patient right away in the process, and there are some basic tenets of trauma-informed care. There are six of them, in fact.

It includes making sure, first and foremost, that there’s safety for the patient. When we think about people who’ve been exposed to trauma, they’ve been in different scenarios where they have been abused psychologically and physically, and so they’re often very apprehensive about coming into an exam room, for instance, with a closed door. So we’ll give them opportunities to have perhaps the door ajar, or to have someone they trust with them in the room. So safety is the first.

The second precept is trustworthiness and transparency, so talking all along the way about what we’re going to do and having the person take part in it. And that leads into peer support, so that we come at the interview or interaction on the idea of being equals, we’re both human beings, rather than there being sort of an authoritative direction where the person who’s the doctor or nurse is in power over the patient. So trying to make that more equal.

And then that leads into collaboration and what we call mutuality. And so again, saying, “Usually at this point in the interview, I’d like to do a physical exam. Is it OK if I put my hands on your back?” or something like that. So you lead into it and make sure that the person, the patient, is involved.

And that leads into empowerment and choice. So albeit there are emergency situations, but mostly I’m coming from primary care, and so in that setting, anything that we do on that particular day is really an element of mutual agreement and choice for the patient. So, for instance, that person may or may not choose on that visit to have their blood drawn, because it’s an invasive procedure and they’re just there for the first time. And so again, giving that openness, so that instead of feeling like there’s just a list of things you have to get through, you’re being much more flexible.

And then the last tenet is to have cultural, historical, and gender awareness, and so just to be aware, again, of the person you’re with, where they’re coming from, what their background is, and to, of course, use appropriate language and things like that.

Kevin Pho: So let’s transition into your KevinMD article. How has trauma-informed care been influenced in the age of COVID-19?

Andrea Reilly: Yes, so I wrote this article because it really started out with a patient asking me a question. She asked me for a letter because she was having trouble wearing a mask, a face mask. She needed to travel. She was going to be on an airplane. She wanted a letter of support from her doctor to say that she couldn’t wear a mask. And of course my initial reaction was, “No, I can’t write that letter. You need to wear a mask. We are in the middle of a pandemic, and you need to protect yourself and those around you.”

But she was very honest, and she told me where this came from. She explained to me that 15 years ago she had been assaulted, and one of the things that the assailant did was put his arm over her face, and she couldn’t breathe at that time. And although she hadn’t thought about this at all recently, the act of wearing the mask over her nose and mouth suddenly was triggering memories of that trauma. And she described very vividly what she went through and the symptoms she went through: heart racing, feeling as if she couldn’t breathe, being frightened. And she did have episodes where she wore a mask briefly while running into the grocery store, but she felt really uncomfortable.

So I thought more about it over the course of the night, and I came back to the realization that, especially if I’m trying to be trauma-informed myself, she’s being honest, telling me about her past background and what it’s doing for her now in terms of triggering those emotions and memories and then the physiologic response, so I could honestly write her a letter to say that this affected her.

Kevin Pho: A lot of us don’t have the appropriate training in being trauma-informed. What are some of the things that we should look out for, for those of us who don’t have formal training in trauma-informed care?

Andrea Reilly: Right. So there are things that we can pick up about patients. A lot of times behavior may seem angry or noncompliant, and really that’s coming from something in the background, something that might have been an early traumatic experience, either in the health care setting or outside of health care. But I think first and foremost it’s to pick up clues on how the person is behaving and then to dig deeper if there are some cues that suggest that there’s something awry.

Kevin Pho: And for those primary care physicians who may be listening to this podcast, I know you talked about the six tenets of trauma-informed care. What are some techniques that you could share, that you could teach them, to be more trauma-informed?

Andrea Reilly: Yes, so it’s very simple. It really gets to the basic connection. Things like making sure you’re eye level with the patient. Things like using language that is not just, of course, their own language, and making sure you have an interpreter if you need it, but also mirroring the words they use, so not using words that they can’t understand, and not talking down to them, just talking to them.

And so it’s really not hard. We shouldn’t be worried or afraid that we’re not providing the appropriate care. It’s really just very simple things: eye level, offering them choices, and just being patient.

Kevin Pho: We’re talking to Andrea Reilly. She’s an internal medicine-pediatrics physician, and she wrote the KevinMD article “The challenge of trauma-informed care in the age of COVID.” Andrea, how has the pandemic affected you and your practice?

Andrea Reilly: Yes, so it’s changed greatly. It’s much harder. Here I am talking about being close to someone, being eye level, and yet now we’re forced to be covered up with a mask and goggles. So I think it’s brought forward a lot of fear on so many levels. And I think we can’t take away the pandemic, but we just have to recognize for one another what we’re all going through. So it’s even harder in the time of the COVID pandemic, but we just have to be aware of that.

Kevin Pho: So one of the things during the pandemic is the increase in virtual visits. So with some of the things that you talked about earlier, how can we have that connection in a virtual setting?

Andrea Reilly: Right. I mean, I think that’s particularly challenging, but one thing I’ve noticed with a lot of my trauma patients is that actually they don’t like doing a video visit. They don’t mind talking on the phone. They find that comfortable and calming, but they do not like having a screen in front of them. And quite honestly, that’s because for some of them, that’s how they’ve been abused. There’s a lot of sexual exploitation that’s screened and then sold, and so, unfortunately, that’s in some people’s background.

And so I think being aware, even when you’re conducting a virtual visit, you just ask the patient, “Do you want to do a video, or do you want to do just a telephone conversation?” And that is often the way to go. One thing I’ll do is I’ll say, “Well, I just want to see you for a moment, make sure you’re OK, and then we can turn off the video and talk.” So that’s one way to do it.

Kevin Pho: One of the things that you mentioned earlier in your story was your work with sex trafficking patients. Now, for those who don’t have a lot of experience in the area, what are some of the signs that we should be looking out for?

Andrea Reilly: Yes, so tap into any past experience you might have had with either intimate partner violence or childhood sexual abuse. So think about physical signs and symptoms. Think about unexplained bruises, things like that. In particular, someone might have marks on the face; facial injuries are very common. So is attempted strangulation, so someone might have marks on their neck.

And the other thing is there’s branding that goes on, Kevin, so people may have tattoos on different parts of the body. I know that seems vague now, because so many people have tattoos, but there are some symbols, sometimes a barcode, often a crown or a dollar sign, that are fairly typical for traffickers to place on their victims.

Kevin Pho: And if we see one of these signs, or if we have a suspicion, what’s the next step? What do we do next?

Andrea Reilly: The most important thing is to be aware, but you don’t want to make it difficult for the patient, because they can be a safety issue. So the thing for all of us to be aware of is there is a human trafficking hotline that we can all access, which is akin to things like the poison hotline, where it’s available for physicians just as much as it is available for patients to use. And so they can give you information; you can provide tips.

I think if you have a patient in front of you that you’re concerned there might be something awry or going on with, you want to just say to them, “I’m concerned about your safety. Please let me know if there’s anything I can do to help you.” Oftentimes very basic needs are what they need. They’re hungry. They haven’t eaten in a while. Food deprivation is often one of the techniques that is used for control.

And because of the danger of the control that traffickers have over their victims, trying to rescue them is not what we’re trying to do. So we’re not trying to divulge past trauma or to rescue. We’re not digging deep into what’s happened. We’re really trying to do an immediate evaluation. So it’s not an issue where you call for police. It’s more an issue of just trying to provide what you can on that day, making the patient aware that you’re available in the future if needed, and letting them know about the human trafficking hotline.

Kevin Pho: And my final question: Do you have a take-home message that you want to share with the KevinMD audience?

Andrea Reilly: Yes, I would say that things are not always as they seem. For instance, in the situation I had with the patient who wasn’t wearing a mask because of her PTSD, I think she was called out by many people and called bad names for what people might have thought was making a statement, but in her situation it was not a political statement at all. And so, because things don’t appear as they seem, it’s our job to ask questions. And so that’s what I would leave you with: There are a lot of invisible wounds out there, and we don’t know if we don’t ask.

Kevin Pho: Andrea, thank you so much for sharing your expertise and your insight, and thanks again for being on the show.

Andrea Reilly: You’re very welcome. Thank you.

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