Mitchell Elliott is a medical student in the Class of 2019 at the University of Toronto
Doctors are amongst the intellectual elite of society. In many cases, with decades of training and continuing education in clinical practice, our expertise grants us the opportunity to do things that would be deemed invasive and inhumane if performed outside of the context of medicine. Selectively poisoning people with chemotherapy; carefully dissecting fascial planes and removing organs; asking invasive and personal questions… all in the name of symptom management, remission of disease, and prolonging the inevitable: death. For physicians, these daily rituals become almost routine. In many cases, we have spent the majority of our lives training for the uncertainty of each day, rigorously memorizing each disease presentation and management principle, habituating to these processes and procedures. With the heavy clinical demands on physicians, it may be difficult to fully realize the impact of our actions on each patient.
Trauma, in the medical context, is defined as “physical injury.” In society, it is defined as “a deeply distressing or disturbing experience.” For many patients, the intentional medically-inflicted trauma is worthwhile; temporary pain for the ultimate gain, symptom relief and prolongation of life. In the treatment process, we inflict the required trauma, the patient recovers, and they are discharged back to the community. With every intervention, providers are balancing patient beneficence and non-maleficence, while granting them the autonomy to make their own decisions. However, how often do we see each intervention from the perspective of the patient? For many, each intervention is novel, terrifying, and often experienced alone. Medicine is, without a doubt, traumatic by nature; patients are never the same as when we took charge of their care. As the countless hours in the hospital have changed us as providers, they also change our patients.
On inpatient psychiatry, you realize that almost every patient has been a victim of trauma, both medical and societal. Being involved in the care of patients fraught with anxiety and depression from prolonged ICU stays, to women with complex PTSD from a culmination of their tragic life circumstances, this becomes ever more apparent. Spending the majority of my core rotation on a women-only psychiatric inpatient unit pushed me not only as a clinician-in-training, but as a human being. I was amidst one of the most vulnerable groups in society — an encounter not often experienced by trainees, nor appreciated for the intimate glance it provides into patients’ lives. These women, from all walks of life, were admitted to the program in hopes of regaining some semblance of normalcy. However, I soon learned that this goal often felt unattainable from both clinicians’ and patients’ perspectives.
Every day was marked with physical, mental, and emotional challenges as a provider. Each conversation felt as though the air was being sucked out of the room; each word uttered made it more difficult to breathe. Stories about incomprehensible traumatic life experiences vividly ran through my mind. I witnessed firsthand the perseverance and strength of these women; it was truly a testament to the innate resilience of the human spirit. However, it was no surprise that patients would often seek any attempt to escape this pain, temporarily numbing the unbreakable bond between mind and body, by any means necessary. This inseparable connection, emphasized with each traumatic event, made it increasingly apparent that we not only experience trauma; we feel it and never forget it.
With the ever-growing focus on patient-centred care, providers must never forget the importance of recognizing past trauma and the potential to induce new trauma through interaction with the medical system. This experience truly emphasized how common trauma is, how it shapes people, and how it can have a powerful impact on both mental and physical health. Recognition of past traumatic experiences is essential to a beneficial therapeutic relationship. Acknowledging these past experiences and having them inform the development of your relationship and management of patients is critical. In addition, providers should ensure that the therapeutic environment is a safe space which recognizes patients’ needs for emotional and physical safety. Furthermore, we should ensure that not only are our actions therapeutic, but also our encounters. Many patients may never understand what we do to them, but how we interact with them will shape their entire experience with the medical system. We should be cognizant of our verbal and non-verbal interactions, ensuring we recognize sensitive factors and approach them appropriately. Finally, it is important to recognize that our interventions may alter a patient for the remainder of their life — even after they leave our care. With this in mind, it is important that we incorporate patients in their healing process, empowering them to make the necessary changes required to regain health.
Caring for people in their most vulnerable moments is an honour and privilege that should not be taken lightly. We must remember that mental health is as important as physical health, and that it is a vital component of holistic, patient-centred care. Although the trauma we inflict as providers may be necessary, we must remember that we should never traumatize patients in the process.
Hello Dr. Verbeek,
Thank you for your comment! I am glad that you appreciated the article.
You have one of the most difficult jobs seeing patients with trauma in the ED. I am sure they appreciate your care to not further traumatize them.
I really appreciate your support regarding the article. I hope to write more about my experiences and would love to continue to share them.
Thank you again for the comment!
Dr. Richard Verbeek
In my busy day I hardly ever make it to the end of an article let alone take the time to comment but this held me transfixed to the end. It has to be one of the best medical “ethics” articles I have ever read. I have worked for 30 years in a very busy teaching hospital ED where I see multiple “traumatized” people every day. While not nearly as elegant as Mitchell, my approach to such patients is to acknowledge their concern, ensure them there are things I can do for them, some of which my be uncomfortable (which could the thing I may need to do or the questions I may need to ask), but reassure them I will take good care of them. Now I realize I am try to accomplish what Mitchell has counselled. I may be inflicting “trauma” but hopefully without “traumatizing”. What a wise insight. Thanks Mitchell!
Dr. Amber Swan
A well written, intuitive blog. Based on my experience working in oncology, I completely agree with the author’s comments. We have to be cognizant of doing our best to minimize traumatic interactions not only for our patients, but also for ourselves (we are not immune to the repercusions as well). As stated, humans actually have an innate resilience of spirit. As healthcare providers, I believe part of our job is to work in such a way that we remind patients (and ourselves) of that. When we are successful, trauma and fear is minimized. Thank you for articulating this so well!
Hello Dr. Swan,
Thank you very much for your comment! I am glad you liked the article. I couldn’t agree more with what you said about minimizing the traumatic experiences on ourselves as well. That is a key part. We cant heal others if we cannot heal ourselves.
I was actually invited to speak at a clinical and basic science oncology conference regarding this topic! I think trauma-informed medicine is a major component of competent cancer care.
Thank you for your comment.
Harry Zeit MD, Certified in Sensorimotor Psychotherapy
Thank you Mitchell Elliott for this article. You left me speechless for a moment (in a good way), speaking so clearly of truths that took me many years to formulate, arising from your own experiences and felt sense. In a way, I think these were the words I always hoped would more deeply inform our profession and our professional journals. Perhaps it is closer than I imagine.
I did share your article on my trauma-informed self-care Facebook page – which supports a self-care program for physicians – this morning, because it does deserve more widespread acknowledgement. I added a little further commentary there (https://www.facebook.com/WhileCaringForOthers/)
Thank you on behalf of all of us you speak for – whether as clinicians, patients, or both.
Hello Dr. Zeit,
Thank you very much for your kind words! I really appreciate the support. This experience is so profound that I hoped to write something that would do it justice. Thank you for sharing it in your group as well. I hope they also appreciated it!
Thank you for your inspiration and practicing trauma-informed medicine! I know your patients value this.