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Join Wendy L. Hunter, a pediatrician, as she shares a powerful story about a teenage girl found alone, having a seizure outside her clinic’s front door. This incident prompted Wendy to explore trauma-informed care in her practice. Discover how Wendy’s clinic implemented changes, such as using risk-scoring tools and community health workers, to provide holistic support to patients. Learn why incorporating trauma-informed principles is essential for all medical clinics, as Wendy sheds light on the transformative impact it can have on patient care.

Wendy L. Hunter is a pediatrician.

She discusses the KevinMD article, “How a teenager with seizures became the face of trauma-informed care.”

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast and get CME for this episode by clicking on the CME link in the show notes. Today we welcome Wendy Hunter. She’s a pediatrician. Her KevinMD article, which we’ll talk about today, is titled “How a teenager with seizures became the face of trauma-informed care.” Wendy, welcome to the show.

Wendy L. Hunter: Hi. Thanks, Kevin.

Kevin Pho: So we’ll get into the article in a little bit. First off, briefly share your story and journey.

Wendy L. Hunter: After pediatrics residency, I worked in an emergency department at a children’s hospital, and I was a primary care pediatrician there. So I was exposed to things that primary care doctors don’t always see, but because I was primary care in the ER, I saw all the kids that came in for non-emergent conditions. That’s where I started my journey to realize that patients need more than we can give them. We have to go to them. They come to the ER because they don’t have transportation to get to primary care. So I started an outreach program where I brought pediatricians into homeless shelters to do health education. Now I’m in primary care myself, and I can still see those hidden kids, and that’s what started me.

Kevin Pho: So you mentioned that in the emergency department you saw things that pediatricians in the office-based setting may not see. What would be some examples of that?

Wendy L. Hunter: Oftentimes I would see really advanced cases of really basic conditions. So, like, the worst eczema that just was never treated. Something really basic that got to an advanced stage where you were getting infections, things that could have been prevented.

Kevin Pho: So tell me, how has your work in the ER influenced you now that you’re in more of an office-based clinical setting as a pediatrician?

Wendy L. Hunter: There are a lot of hidden kids out there, kids who are not going to school. They’ll claim to the school district that they’re homeschooled, but really they just aren’t going because their parents can’t get them there; they don’t have the resources to get there. I have seen kids where, if you go over a diet history on a kid with obesity, you realize they don’t have access to fruits and vegetables. They only have the corner store, and of course they’re going to eat frozen pizza every day, because that’s less expensive. So those are the kinds of things I saw in the patients in the emergency department who were there for low-acuity problems.

Kevin Pho: So what’s your practice like now? Take us through a typical day.

Wendy L. Hunter: What’s funny is that I am in a really wealthy neighborhood now. I am part of probably close to the largest, I think we’re the second-largest single-specialty group in the country. It’s called Children’s Primary Care Medical Group. We’re based in San Diego and Riverside counties in Southern California, and we have 160 pediatricians in our group and something like 24 or 26 offices now. So I’m part of that group, and I’m in one of our wealthier neighborhoods.

We all do take public insurance, so we take Medi-Cal, which I think really makes us stand out. The other thing about our group is that we treat behavioral health conditions. It’s pretty uncommon to find a group like this where we treat anxiety, depression and ADHD in-house, and that’s partly what attracts some of our patients to us. That’s why I wrote the article: It involves one of those patients.

Kevin Pho: All right, so let’s talk about that article. It’s titled “How a teenager with seizures became the face of trauma-informed care.” So tell us the story. How did your article come about?

Wendy L. Hunter: It’s important to have anecdotes as doctors. If we’re going to get attention for things, we need anecdotes. And I really appreciate the KevinMD platform, because it allows me to tell a story on there that I can then share with other people. If I share it with my organization, it has more gravity than if I tell this story in an email.

So this is how the story went. This is an incident that happened in my clinic, which, as I said, is in a well-to-do neighborhood. The dental hygienist from one of our neighboring offices happened to walk by the front door of our office and saw a teenager having a seizure on a bench right outside our office door. So she came in and said, “There’s a teenager out here. Does she belong to this clinic?” I went outside, and we couldn’t find anybody. Then I talked to our front desk person, and he said, “There’s a mom back in the clinic room. She’s been coming in and out the front door maybe five times. I think she might be the mom.”

So I went and found her, and in fact she was the mother. She was in our clinic with her son, and she had been bringing her son to us for about six months for behavioral health treatment. She knew if she missed an appointment she wasn’t going to get his refills, so she was very diligent about her follow-up. We never knew she had a daughter. She had just gotten insurance for her son; she didn’t have insurance for her daughter. And it turns out they were homeless. Mom was living in a tent, the kids were living with their father, and the daughter had had seizures for about a year.

So this is what the mother is telling us as we’re standing there watching the daughter seize. Mom tells us, “She’s been having seizures for a year. She doesn’t have insurance. I have figured out that if she doesn’t run, she doesn’t have a seizure, so I never make her run or exert herself.”

So why did she have a seizure that day? Well, they had been on the bus on their way to our clinic, and Mom realized they were going to be a little bit late. So she called our office and said, “We’re going to be 15 minutes late.” And as most offices say, our front desk said, “Well, if you’re more than 15 minutes late, you’ve missed your appointment.” So to this mom, in this condition, in this situation, she knows she has to make it there. So she gets her kids off the bus, they run to our office, and her daughter has a seizure. And she’s by herself, so she leaves her daughter outside on a bench. It makes perfect sense.

But what I gained from this, what I learned from this, is that I was really struggling with what trauma-informed care meant. Trauma-informed care means that at every touch point you have with the patient, you look at it with an understanding lens, with compassion. You don’t know what’s going on in that person’s life, and you don’t know how they’re going to respond. So when we say to our patients, “If you’re not here in 15 minutes,” for some people it’s, “OK, I’ll be there, I promise,” no big deal. But for others, this means a seizure disorder. This is a life-threatening condition.

So in my clinic, I’ve been in charge of our trauma-informed practices for all of our clinics, and we’ve introduced ACE screening, so screening for adverse childhood experiences among our patients. That was just the very beginning of trauma-informed care, and that’s what I want to focus on going forward.

Kevin Pho: So tell us, in terms of ACE screening and trauma-informed care, what would that look like in the exam room?

Wendy L. Hunter: Trauma-informed care starts in the front office. It starts when you make an appointment. So one of the things that we have been doing, and we’re working on now, is scripting for our front office, so they’re giving the same message to every patient. And we’re really evaluating what level we’re speaking to our patients at. You have to speak to them at a third-grade level. Make sure they know what you’re saying, make sure you have translators available, and then your signage in your office. That’s part of a trauma-focused office.

Then in our daily practice, we do offer behavioral health. We have a grant to have community health workers in some of our offices to help as health navigators. I think if we had had one in our office, this mother might have felt like she had a person she could talk to and say, “Hey, I don’t have insurance for my daughter. Can you help me?” That might have helped her on her journey.

And then we’re screening at well visits for adverse childhood experiences. We screen mothers and fathers and other caregivers at the six-month visit, so we’re asking parents, “What has happened to you that you think can affect your child?” And what we found is that we don’t have to do any intervention whatsoever. When a parent knows that we care, that’s actually therapeutic enough. Then we’re screening for children’s own adverse childhood experiences at their well visits.

Kevin Pho: Has this been a big change from what you previously did? Is this normally done by a lot of pediatricians?

Wendy L. Hunter: This is a big change for all of us, and that’s why I wanted to get this out there. I have a couple of other articles that I’ve written with you where I’m trying to explain what we’re doing and the challenges we’ve met in introducing screening for adverse childhood experiences. No, this is brand new. I don’t think anybody has any experience with it. So that might be my takeaway message: Nobody knows how to do this, so just start. Just try. It’s better than what you were doing.

Kevin Pho: Now, how did you learn about this? Is this typical in a lot of pediatricians’ training, in terms of trauma-informed care? Is this something that you had to take classes for, or learn from a website? How did you learn how to do this?

Wendy L. Hunter: That’s a great question. I haven’t been in training in a while, so I hope that it’s part of training now. I first learned about it by going to a conference, so you want to look for those specialty talks at the conferences you go to. I went to one on social determinants of health probably 15 years ago, and that’s what opened my eyes to the concept that our health is very much associated with what has happened to us and what our environment is like.

Kevin Pho: So you mentioned how anecdotes are so important. Is there a success story that you can share with my audience, in terms of how this trauma-informed approach has moved the needle in one of your patients or patients’ families?

Wendy L. Hunter: It’s been really helpful for the clinicians, I think, in terms of especially those frustrating diagnoses. When you ask me that question, the first person that comes to mind is an 18-year-old girl who I saw in clinic. She came in for anxiety, for an evaluation, and we are routinely doing the PEARLS, the Pediatric ACEs and Related Life Events Screener, at our behavioral health visits. This is a girl who has been in our clinic probably since birth, actually. Her PEARLS score is out of 17, and she scored 14 out of 17.

Kevin Pho: So what does that mean, 14 out of 17?

Wendy L. Hunter: It’s a really high score. In adults, we use the ACE screen, and it’s scored out of 10. The science tells us that if you have a score of four or higher, that’s very closely associated with a lot of long-term health effects, including substance use, depression, anxiety, hypertension, stroke and asthma, a lot of those things. So in kids, we do still consider a screen positive if they score more than four. And as an aside, we actually will often raise our eyebrows with a score of one, because that means you should at least bring it up and talk to them, and a lot of people underreport.

So this girl scored a 14, and I stopped and I said, “You’ve had a lot of bad things happen to you. Do you think that this is affecting your mental health now?” It was the first time she had ever talked about any of these things with anyone, and it was 100 percent related. What’s interesting is that the data shows that when you treat anxiety or depression in a person where it’s caused by trauma, and sometimes they are caused by trauma, we find that SSRIs don’t work. So it’s a really important piece of the puzzle to know, because they need trauma-based care. They need trauma-based therapy. Trauma-focused CBT, or cognitive behavioral therapy, is the right choice for that, and I could give her Prozac forever and it would make no difference in her life.

So she felt, I think, very healed just by the fact that she could tell me that. And when I went back to her pediatrician, who had referred her to me, and told her what had happened, she was like, “I had no idea. All those years that she came in for headaches and stomachaches, and I couldn’t find a reason.” It was from what was happening to her. It wasn’t a primary pathology.

Kevin Pho: So once you uncover a high score, or any score at all, you mentioned things like CBT therapy. Tell me about the next steps. What do you normally do in terms of addressing this?

Wendy L. Hunter: Opening a conversation is the most therapeutic thing you can do. I mean, most people, especially with their pediatricians, but with their doctors, feel like it’s a trusted person, and they’re an authority in the patient’s eyes. To have one of us look into a patient’s eyes and say, “I care about what happened to you,” that often tends to be all they need.

As an organization, when we were going to start screening, we expected what I’m sure most of your audience feels: “Oh God, I cannot open this can of worms, because what am I going to do with these patients when they tell me all their problems?” So we planned for that, and we had lists of resources. People need surprising things. They need legal resources for immigration issues or divorce issues, or having mold mitigated in their homes. I mean, those are the kinds of things we don’t know how to help with. So we did try to put together lists, and it’s turned out we really haven’t needed them as much as we expected we would.

The other thing we did is we partnered with a community organization that we can refer patients with high scores to. What we’re doing now is we have a fax that you can automatically send electronically from within Epic, so within our EHR. It’s like a letter, and you only have to fill in two fields, and then it automatically gets faxed to this organization, and they proactively call our patients who have high scores. Most communities do have an organization that you can have a partnership with, and they can provide the support. So that’s an option for a lot of people. But what we have found is all they really need is us. And if you’re too busy, you can always have them come back.

Kevin Pho: And as you said before, simply asking the questions has tremendous benefit. We’re talking to Wendy Hunter. She is a pediatrician. Her KevinMD article is titled “How a teenager with seizures became the face of trauma-informed care.” So Wendy, for those pediatrician and primary care offices who want to incorporate more trauma-informed care and more screening in their offices, where do you suggest that they start?

Wendy L. Hunter: There’s a great website called ACEs Aware, and that can be really helpful. I think that is a California website, but I think that our state is probably leading the efforts on being organized about this. So that’s a good resource. It’s got a whole clearinghouse of articles and a toolkit on how to do this. The first step is to have buy-in from your organization, so from your leadership. They need to believe that this is important, and that’s the first step in the guidebook.

Kevin Pho: And did you have any issues with your leadership when you wanted to incorporate this?

Wendy L. Hunter: Well, for us it came top-down, so that was really fortunate. That’s where it came from. Plus, in California there’s money behind this. We get reimbursed by insurance for doing our PEARLS screens. It’s challenging, and it’s been a lot of work to make those contracts, because a lot of the insurance companies include this in their group fund. But on a lot of them, we do get paid individually.

Kevin Pho: My final question, Wendy: Tell us some of your take-home messages that you want to leave with the KevinMD audience.

Wendy L. Hunter: Really, it’s just don’t be afraid to try this. You can literally print out the ACE screen or the PEARLS screen free online and just have them on your desk. If you have a patient who is just coming in with chronic pain issues, and you just can’t find anything wrong with them, this is a really good approach. Give them a PHQ, screen them for depression with that tool, and give them an anxiety screener and the ACEs, and you’re going to open a conversation that really leads to a better diagnostic evaluation.

Kevin Pho: Wendy, thank you so much for sharing your story, time and insight. Thanks again for coming on the show.

Wendy L. Hunter: Thanks, Kevin.