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Dr Pam Peeke: Welcome to Better Edge, a Northwestern Medicine podcast for physicians. I'm Dr. Pam Peeke. And joining me today is Dr. Traci Kurtzer. Dr. Kurtzer has more than 25 years of clinical experience in menopause, sexual medicine and vulvuvaginal conditions. She's also the Medical Director of Trauma-Informed Care and Education in the Department of Obstetrics and Gynecology at Northwestern Medicine and provides specialized gynecologic care to patients with a history of sexual abuse, assault and medical trauma.

Dr. Kurtzer joins me today to discuss the topic of trauma-informed care. Dr. Kurtzer, it's wonderful to welcome you to the podcast.

Dr Traci Kurtzer: Yeah. Thank you so much for the invitation and opportunity to talk today about this topic.

Dr Pam Peeke: So I think it's always important to start with definitions. How do you define trauma?

Dr Traci Kurtzer: That's always a really good first question because so many of us, even those of us in healthcare, usually default to think of the word trauma, meaning physical injuries, like those due to accidents or violent acts. But when we're talking about trauma-informed care here, what we're referring to is actually quite broader.

So, the SAMHSA definition really is a nice succinct way to think about it, which is trauma includes any event or series of events that one has experienced over their lifetime that's perceived to be either emotionally or physically harmful, or it even can be life-threatening to somebody. And that it ends up having lasting adverse effects on our functioning, and that can be at the physical level, social or mental well-being.

So I like to think of cumulative trauma burden is really coming from three big areas or general areas. Usually, I think of it like collective trauma, some of the things that we've maybe inherited from our families of origin or the groups of people with which we identify with and also include like major historical events that can be life-threatening, things like hurricanes; the pandemic we're going through right now, it's just affecting our generations. Gun violence for the younger generation is a source of trauma.

And then, second can be interpersonal traumas. Those are a little bit more relatable for, I think, people which is things is early in life is school bullying, workplace abuse. And it goes all the way up to really severe forms of physical or sexual violence. And then last we have just kind of our individual trauma experiences or harmful experiences in our lives. So those can come from our childhood dealing with chronic serious health issues. And even up to just kind of current and day-to-day stressors from social determinants of health.

So lots of different things that can contribute to the trauma in our lives. And, because of that, really no two individuals are going to have the same experiences or impact from their trauma. And there's just so many different sources, degrees of harm and other mitigating factors that play a role.

Dr Pam Peeke: Yeah. You know, it's interesting. I'm so glad you just said that because trauma in many respects is in the eyes of the beholder, right? And so trauma could be the divorce of parents and you're five years old and now you're 55 and you talk about it like it happened yesterday, whereas somebody else just blew right through it. And so, so important to honor that unique individual's issue. I'm so glad you defined it as such. So what then is trauma-informed care?

Dr Traci Kurtzer: So for trauma-informed care, as a medical care system, we're basically providing as practitioners, trauma-informed care means we're aware of the prevalence of the trauma. So all those things that I just spoke about, that they can be impactful. And we're aware of the potential impact on the health conditions or health outcomes for our patients. So just, basically, we have to take that into account during the visit and when we're providing treatment recommendations.

And I think a really important part of trauma-informed care, one of the most important things, is that we're doing our best, not to actually contribute to that cumulative trauma for our patients through our words and actions because medical biases and medical trauma are contributing issues there.

So there are some other principles that I think we should aspire to when we're being trauma informed in the patient physician relationship, things like providing a real sense of safety for our patients when they're visiting us in the office. Of course, being trustworthy and transparent. And then collaborating with our patients, we want to give them and encourage a sense of control and empowerment in their healthcare. So, you know, all of us are patients too. We all really benefit from this patient-centered approach from all of our healthcare professionals.

Dr Pam Peeke: Tell us about your goals for the Department of Obstetrics and Gynecology at Northwestern Medicine when it comes to trauma-informed care and education.

Dr Traci Kurtzer: Oh, I would love to. So I would say actually even broader, ideally I would say really our entire healthcare system staff that care for patients would be trauma-informed. And we're certainly not there as far as the extent of education. But my role here at Northwestern, in our department is not only be one who provides trauma-informed gynecologic care, but also as the Medical Director of Trauma-informed Care Education. I teach others in our department and other departments across our NM system and even at outside institutions on how to provide this type of care.

But I would say, especially in our field with the prevalence of sexual trauma in our patients, you know, keep in mind that one in three women are sexually assaulted, one in five are raped in their lifetime. I think it's really critical for us to be aware of the impact of those forms of trauma when working with our female identifying or gender non-conforming patients who are getting obstetrical or gynecologic care. So my goal is definitely to have all of our department members well-versed in understanding that prevalence and taking that into account when taking care of our patients.

I also really do feel like it's important, another component of trauma-informed care means taking care of ourselves, right? Kind of the physician heal thyself aspect. And so I do think it's important for medical centers or offices that really want to be trauma-informed to kind of recognize that our medical staff, other staff are human too. So we come in with our own histories of trauma and then, in additiona,we can suffer from vicarious trauma from caring for our injured or sick or traumatized patients.

So ideally, I would say it even is more expansive than that, having our nonclinical managers and administration also trauma-informed to understand this better and to be able to provide additional support for their staff, especially those who are at high risk for compassion fatigue and burnout. So that would be, I would say another real important goal of mine for our department and for our system as well.

Dr Pam Peeke: Oh, my gosh. I am so glad you included us providers. We're caregivers and we care so much about that patient. But oftentimes, we forget about ourselves, we fall off the radar. And I really think it's admirable and it is so important to be able to recognize that we're human too. And I love the fact that your program acknowledges that and respects that, honors it in a big way.

Now, if we pivot to the patient now, I think one of the biggest challenges sometimes is to identify a patient who may be experiencing or has experienced trauma because, as you know, they oftentimes hide it, and they've gotten used to doing that. So what are some signs that physicians should be looking for during that visitor exam to really identify that patient?

Dr Traci Kurtzer: And you're absolutely right. I mean, I think most often we're really not going to know if a patient has a significant history of trauma. Although I will say, it's so fascinating to me, I do feel like more and more patients are speaking with us about past adversities or informing us when they have had trauma when being screened than in the past. So I'm hoping, with normalization, and some of the movements out like Me Too and awareness of racism being accelerated, I think, in medical care then hopefully people will be more willing to share that. But the reality is disclosure's not really necessary. We just need to kind of universally treat all our patients with these techniques.

I would say though, that if you have a patient that one might consider kind of their "difficult patients", and I hate to use that term, but those patients who maybe have been struggling with compliance or who seem really angry or frustrated with us, or those who respond kind of in unexpected or inappropriate ways when we're counseling them or during an exam as well, definitely think about trauma. And so I always tell my staff and have to sometimes remind myself too, that instead of getting exasperated and thinking, "Gosh, what is wrong with this person?" I just really tried to shift my internal dialogue to what must have happened to the person to make them react this way to me, because most people are seeking us out for help and, generally, there's a trust that has to be there from the get-go for them to walk in the door. So if they're struggling with this in these ways, that usually means they're having a trauma reaction.

So I think recognizing that really helps us reframe some of our interventions. It's going to definitely help prevent us from getting defensive in response to them, which is only going to potentially cause that retraumatization. And then there's certainly things that people can be aware of during an exam. So I'm happy to share those too.

Dr Pam Peeke: Yes, because, you know, what are the kinds of things that you can discover during the exam? And also what are some useful techniques that physicians can use when approaching a patient with known trauma?

Dr Traci Kurtzer: Right. So, definitely things to be aware of during exams, and so clearly if you have a patient. particularly with gynecologic exams, who's wincing or crying or kind of abruptly withdrawing from our touch, which can also happen in just general physicals, that would be concerning.

I would also say, one of the most serious signs of trauma reactions is dissociation, which is basically staring off and not really responding to us. And so forseeing that, that's a pretty extreme form of a trauma reaction. And in that case, stopping what we're doing immediately and having some grounding techniques at your fingertips are really helpful to help bring the patient, because basically in that situation, you need to bring them back to the here and now because they're often to another zone. Their brain is kind of shut off because of the reaction they're having. So we need to do things to help them feel safe at that point. and that's really critical.

For those patients that have a history of trauma, who report getting really easily triggered into trauma reactions, if they're open with you about that, you can actually do some grounding and calming techniques even before and during the exam with them. And really, I just have to stress this so much at this point. I think what's really critical is we may not be successful. And even when we're doing the best we can, some people still may get into a trauma reaction and trying to not take it too personally for sure. But also I think the really important thing is to not get angry with the patient. It's really somewhat out of their control. And especially don't get angry or frustrated if we're not able to complete the examination, especially a gyne exam, even if it's going to make our jobs a little bit harder, But again, it's just out of their control. It either is because they have a medical condition that's causing severe pain and reaction or past trauma. And at that point, it's kind of up to us to try to figure that out or to refer to somebody like me, who can kind of take the extra time that's sometimes needed to help patients figure that out.

Dr Pam Peeke: Dr. Kurtzer, can you just give us an example of grounding and calming techniques?

Dr Traci Kurtzer: I think a lot of them are often around breathing, but not everybody has good breathing skills. And so I've started doing like anything that really engages the senses can be helpful. Some people will have to squeeze balls or something that patients can kind of touch and feel. Having pictures or some visual materials in the room that you can have patients focus on or even just using a little mental, sensory grounding. Can you see something that the blue in the room? Can you tell me something that's green?

I've started doing a technique which involves rolling up and down the fingers with one hand as you're breathing, because it has a little bit of a calming rhythmic motion to it and it helps remind people to breathe. And that's when I'll use a lot with my trauma patients that we know upfront so that they can do that actually throughout the exam.

Dr Pam Peeke: Absolutely. And I'm so glad you've stressed that. So looking at a larger picture here, Dr. Kurtzer, why is it important for other physicians and healthcare systems to use this approach of trauma-informed care?

Dr Traci Kurtzer: Hopefully, after just having this discussion. I think we can all relate because we're patients too. So hopefully, you can say if you had a physician that was helping you feel safe in that environment and really collaborating with you that that would be clearly something that we all benefit from.

But in a bigger sense, if we kind of look at this, even from a public health standpoint, trauma-informed care has definitely been demonstrated as one approach out of many to help address some of the health inequities that we face. As we all know, certain groups of patients like for example, our black brown and LGBTQ patients are certainly more likely to have some of these intersections of multiple forms of trauma and severe trauma and then of course can be additionally harmed by, dealing with the biases they encounter with us and lack of cultural awareness by us, their healthcare providers. So being in tune to that's going to help with leveling the field a little bit, and how patients are able to access care and follow up with care.

And a few studies that have looked at outcomes in systems that have implemented trauma-informed care, patients reported higher satisfaction with their care. But they also felt more engaged in their health outcomes. Referrals are more often completed, no show rates drop, and ER visits are reduced as well. So utilization in outpatient and inpatient systems is going to really help overall.

And then, looking at ourselves, you said you appreciated that thinking about the professionals. And we know that healthcare professionals who provide this care also often report greater satisfaction with the care they're giving. And in one study that was done, the hospital employee retention rates were higher when they implement a trauma-informed care. So I think we really all benefit across our system when our experienced colleagues stay put, and don't burn out and are able to continue to provide exceptional patient care like we do at Northwestern.

Dr Pam Peeke: So. Right now, I'm sure a physician is listening is thinking about, "Well, how do I refer a patient to your program at Northwestern Medicine?" And what is the process by which they do that? What types of patients should they be referring to your wonderful program?

Dr Traci Kurtzer: Well, I am a gynecologist, so we have to keep that in mind. And I would say, so for referring specifically to me, I would say definitely feel free to send any patient my way who's definitely been struggling with their gynecologic exam, and that could be either due to just fear but pain for sure. And that could be because of past sexual trauma, medical trauma, or who knows why, but any patient that has experienced sexual assault and needs the followup care from being seen in the emergency room or especially those who didn't make it to the emergency room, because we really know only about 30% report their assaults. So we're seeing many of these patients who have had that experience, but actually haven't gotten any followup care and I can assist those patients with certainly any important medical care that needs to be done, but also a little additional psychosocial support and referrals for those patients as well. So those would be the folks that I would be seeing here at our center.

And to refer directly through Epic, you can actually just put in a referral under Menopause and Sexual Medicine, which is referral 5 8 7, and you can just put my name in as a physician, if you want to write some notes, you can put trauma-informed gyne care or a TIC. And then, our coordinator will get the patient connected, or you can just have the patient connect with us directly, (312) 694-9676 is our scheduling number or via our website, which is sexmedmenopause.org.

Dr Pam Peeke: That's fantastic. You know, as we begin to wrap this up, I was hoping you could gift all of our listeners with one last word of wisdom that you think will help providers as they begin to fully appreciate trauma-informed care.

Dr Traci Kurtzer: Well, I would say, again, really important to remember ourselves because it's very hard to be a trauma-informed care physician if we're not also giving some self-care. So I know that on a personal level, getting the patient feedback and the positive comments definitely help sustain us all in this intense work. But many of us who do this work with highly traumatized patients, and I want to say, I'm not alone here. I'm thinking of all my colleagues across Northwestern who are dealing with highly traumatized patients and families due to particularly the challenges of COVID this year, but even just chronic health disparities and chronic illnesses on a daily basis.

So, I just want to remind everybody to be aware of the effects of vicarious trauma and how that can sometimes lead to compassion fatigue and burnout. We really need to get support from our supervisors and peers. So I will say again, working altogether towards a trauma-informed transformation for our whole system from top to bottom, and I'm going to continue working on this for all of us.

Dr Pam Peeke: Oh, thank you so much. Dr. Traci Kurtzer, you are just fabulous, Medical Director of the Trauma-Informed Care and Education in the Department of OB-GYN at Northwestern Medicine. Thank you very much for all of your information. And I know that the physicians who've been listening have been taking copious notes and hopefully are now much more aware of the need for trauma-informed care.

Now, for all of you out there, to refer your patients or for more information, head on over to our website at NM -- that's Northwestern Medicine -- dot org to get connected with one of our providers. And that wraps up this episode of Better Edge, a Northwestern Medicine podcast for physicians. Please remember to subscribe, rate and review this podcast and all the other Northwestern Medicine podcasts. For updates on the latest medical advancements and breakthroughs, follow us on your social channels.