‘Health equity and trauma-informed care: a humanistic approach’

‘The Sole meaning of Life is to serve humanity’—Leo Tolstoy

One of the hallmarks of civilization is the idea of humanity, that humans ought to want to take care of one another and be empathetic to each other’s needs. Trauma Informed Care (TIC) builds on this basic tenet of empathy and requires us to elevate our empathy to the next level, considering the conditions that our fellow humans are subject to and how it may affect their reactions and behavior in the healthcare setting.

The study of TIC is not new, but the proliferation of knowledge and resources about trauma-informed practices has seen a sharp increase in the past decade. The understanding of adverse childhood experiences (ACEs) and their effect on health outcomes originally stemmed from sentinel work done in the 1990s,1 which taught us that children exposed to adverse psychological experiences in childhood have a higher rate of organic diseases such as asthma, diabetes and heart disease.

Subsequent work has demonstrated that ACEs are linked to multiple poor health outcomes.2–4 Furthermore, adversity experienced by entire populations is passed on to future generations through a process called epigenetics, in which protein tags on the genome are ‘switched’ on and off.5

Mitigating the toxic stress experienced by generations of adversity requires a trauma-informed approach to patient care.6 In this excellent article in TSACO, Hart et al7 not only help us understand the 4 ‘R’s of TIC that we can employ in our daily practices but are taking our understanding even further, demonstrating not only that we can mitigate toxic stress when we use trauma-informed practices but can also advance health equity. In particular, the language we use is critical to demonstrating our understanding of trauma-informed practices. In doing so, we understand that health equity is not just about access to healthcare services but also about the trust that an individual has in the healthcare system. When trauma-informed practices are not used, individuals, particularly from marginalized groups, are less likely to seek healthcare, more likely to leave hospitals against medical advice, and less likely to comply with a healthcare plan.8 9 Trust, comfort, and the ability to navigate oneself within complex healthcare systems are therefore key components of health equity. To strive for health equity, we must not only provide needed resources but make those resources accessible in a humanistic way, including in the language we use.

In addition to the individual patient interaction, the lack of trauma-informed language in the electronic medical record (EMR) can create health equity barriers and barriers to access for patients. When biased language is used in the EMR, patients may be denied access to critical programs or resources. Discharge planning and rehabilitation options may be limited when biased language is present in the medical record. Trauma-informed language is directly linked to improved health equity in these cases of access to resources.

As we constantly strive for a more humanistic approach to our medical care, we must use language that is culturally appropriate and trauma informed, and Hart and colleagues have given us the tools to do that in their article. Unfortunately, stigmatization and assumptions that are often rooted in conscious or unconscious biases have been pervasive for generations of physicians, and now permeate our vernacular. We now understand that the colloquial nature in which we have discussed injuries, patients, and the circumstances of their injuries is not only rooted in these biases but is actually damaging to the patients as it is counter to trauma-informed practices.

There are, fortunately, things that we can do as individuals to advance the cause of TIC and, by association, health equity.

1. First, all practitioners should be trained in TIC. If you need resources to train yourself or your staff in trauma-informed practices, these can be found at www.sahmsa.org. The American College of Surgeons Committee on Trauma has also recently developed a TIC curriculum that has been piloted at 23 trauma centers and trained over 1500 individuals. This curriculum can serve as a resource to those who are seeking to train their workforces in trauma-informed practices. The pilot is currently going through an evaluation process and the ‘2.0 version’ will be widely available, as will be opportunities to become instructors (more than 130 people have already been trained as instructors). The next edition of Advanced Trauma Life Support includes not only a chapter on TIC, but TIC is woven throughout the entire course. As the authors of this article appropriately address, the topic of language is central to the application of TIC, verbally and in the medical record.

2. If you find yourself thinking about or using language that is not trauma informed, be curious with yourself and ask yourself why this is. Learn about your own biases or consider taking an implicit bias test. Talk to your colleagues and leadership about how you can better understand implicit bias and its implications.

3. When you identify incidences of implicit bias, call it out in real time, coming from a place of kindness and respect for your colleagues. If you hear language that is not trauma informed, suggest ways that the situation could be reframed to use trauma-informed language. Educate your colleagues in real time about the importance of trauma informed practices and encourage them to learn more.

4. Finally, we must take care of ourselves and our teams. At times, the use of language that is not trauma informed may come from an attempt to dissociate or use cynicism or perceived humor to cope with the very raw and difficult environments in which we work. Take a step back and encourage self-care or stepping away from a stressful situation when it is appropriate to do so. The American College of Surgeons Committee on Trauma TIC course addresses vicarious and secondary trauma as part of the curriculum by having learners speak with a mental health professional.

By elevating trauma-informed practices, we are promoting health equity. Equitable care should be the gold standard that we all strive for in our practice of medicine and surgery, and indeed, in our practice as humans who care for one another.