Okay, good afternoon. I am Dr. Megan Riehl. I think we'll get started and we'll just have people join us as they grab their lunch or we'll just enjoy our time together as more of a small intimate group here to talk about a very important topic that each of you have identified as understanding the importance of this topic. I am a GI psychologist at the University of Michigan and associate professor of medicine and I'm very excited to introduce you to Dr. Christina Joukowsky. She is an assistant professor of medicine at the University of Michigan as well in our GI behavioral health program and she's really been doing some phenomenal work in the area of trauma and GI health. So we're going to start our program today and then we'll lead into some case conceptualizations and make sure that we save time for any questions. So I will invite Dr. Joukowsky up to begin. Thank you Dr. Riehl. So here's a look at our disclosures. Can you guys hear me okay? So here's a quick look at our agenda for today. So we're going to start by just talking about what psychological trauma is and then get a little bit more into how it fits into the GI setting and then more narrowly into the public floor space and then we'll spend the bulk of the presentation really talking about some specific trauma-informed strategies that you can be thinking about incorporating into your practice and then we'll end with case examples. So before we get started I just wanted to level set for a second that I'm aware that that that perhaps not everyone in this room and probably most of you are are not clinical psychologists or trained mental health professionals. Perhaps maybe some of you are and if so welcome. But in general I'm aware that not everyone who is in here has received training in this area and that this can be an area that is sensitive in nature and can be uncomfortable as a provider to navigate and so we're very aware of that. When I first started looking into this area it was about eight years ago when I was on fellowship and I had just started talking to some of our attendings of various ages and various places in their own careers and I would just ask them, you know, how do you handle trauma and and with your patients? Do you screen? I was just kind of trying to get a feel for what their practices were and across the board all of those providers who are all very good clinicians that have great relationship with their patients, people I have a lot of respect for, all of them said I just we just don't. We just don't address this area and you know the feedback that I got from them was it's not that we don't think this is important. It's not that we're not aware that this is an issue. By coming up in our training we were often told that if you handle this wrong, if you ask a question and you don't know how to handle that properly, you can actually cause more harm than good and therefore it is in our best interest to not bring these things up if we don't know what to do with it and so that fear of failure can really hold us back from addressing important issues in this area and so going forward my hope is not that through going through this presentation that you're going to walk away, you know, just feeling fully confident and know exactly what you want to do from a trauma-informed perspective but I do hope that you're able to walk away with some specific ideas that you can take home and apply in your clinics and share with your colleagues and start conversations. So first let's just do a brief overview of what psychological trauma is. So you see the definition here from SAMHSA. So it's an event or series of events or set of circumstances that it's experienced by individuals as physically or emotionally harmful or life-threatening and that can have lasting adverse effects on the individual's functioning and mental, physical, social, emotional, and spiritual well-being. So just a couple key points from that definition. So at this we could be talking about one specific traumatic event. It could be repeated traumatic events. So for example, we think about abuse, childhood abuse, you know, repeated exposures to traumatic events. We also know there are many people who have experienced multiple distinct traumatic events over their life. Maybe events that happen in childhood, events that happen in relationships, you know, that, you know, experiencing a natural disaster in adulthood. So we just want to start thinking more broadly about what trauma is. So you see that there are several examples of here of events that can cause psychological trauma. They include history of various types of abuse, combat trauma, experiencing a natural disaster, and medical trauma. And that's what we'll talk about quite a bit today. And there are others examples beyond this. So kind of one of our first take-home points is thinking more broadly about what trauma is and who it affects. So we also know that trauma is common as some of the statistics from Veterans Affairs show that approximately 60% of men and 50% of women will experience at least one traumatic event in their lifetime. And so while people may not always be talking about this, this is certainly an area that many people keep to themselves or keep private, if you think about the people that you encounter both in your clinic but also just in your everyday life, many of the people that you know have experienced at least one traumatic event. These are just some statistics regarding certain types of trauma. So in terms of rape and sexual assault, 1 in 6 females and 1 in 33 males have experienced an attempted or completed rape. Approximately 1 in 4 girls and 1 in 13 boys in the U.S. have experienced childhood sexual abuse, and 1 in 3 men and 1 in 50, sorry, 1 in 3 women and 1 in 50 men have reported a history of military sexual trauma. And then in the intimate partner violence space, about 27% of women and 11% of men have indicated experiencing IPV. So let me say this is just a couple of different types of trauma, but just to give you an idea about how common it is. And also we know that there's a stigma in trauma that it tends to happen more to females. And certainly some of the statistics back that up in that there are certain types of trauma that females are more likely to experience. But as you see here, if you plot that out to what it means for 1 in 13 boys to have experienced childhood sexual abuse, that is a lot of boys that have experienced that type of trauma. So trauma happens to people of all genders. So post-traumatic stress disorder is a specific clinical mental health diagnosis. There's a specific set of criteria. I won't go over that today. But that someone needs to meet in order to get that diagnosis. And as you see here, the lifetime prevalence in the U.S. of developing PTSD is about 6%. So not everyone that experiences a traumatic event is going to go on to be diagnosed with PTSD. There's a number of reasons for that. Again, due to time, I won't go into that. But that can include the type of support they had around the time of the event. Were they able to disclose? And did they receive support? Or was their report dismissed? Did they feel like they had to hide this? Was there shame around the event? These are all some factors that can contribute to the development of PTSD. Women are more likely to develop PTSD compared to men. And veterans are more likely to have PTSD compared to civilians. So now we're going to spend the rest of our time talking about trauma in the GI setting. So we know that patients with a history of GI complaints are more likely to report a history of psychological trauma. We have data really going back into the 90s. So Doug Drosman was one of the first people to start looking in this area. And we have really, there's just a couple cited here, but there's at least 10 studies that have shown similar findings over the years. A lot of that research has been done with patients with IBS. But we also know that patients with IBD have experienced trauma. And patients with multiple GI diagnosis have experienced trauma. And then looking more at medical trauma, Tiffany Taft and colleagues have been looking specifically at disease-related post-traumatic stress. And in one of their more recent publications, they found that between 25 to 33 percent of patients with inflammatory bowel diseases reported significant disease-related post-traumatic stress. And then looking more specifically in the pelvic floor area, there's been a couple of studies looking at this area. These are small studies, so I don't want to extrapolate too much from this. But in those studies, they found between 22 to 33 percent of patients with dysenergic defecation or evacuation disorders reported a history of abuse. And around 75 percent of patients with constipation or disorders of evacuation who underwent anorectal manometry or balloon expulsion testing indicated a history of early life adverse events. I didn't put this on the slide here, but one of the interesting findings from one of those studies was that when they looked at who benefited more from pelvic floor physical therapy, they found that actually patients with a history of trauma, and in this case specifically abuse, were actually less likely to get benefit from pelvic floor physical therapy than those patients that did not. Again, small study, so I don't want to extrapolate too much from that. But there are potential reasons for that. One, it may mean that those patients would benefit more from psychological treatment that really targets the trauma itself and that that might aid in healing. And also, that history of trauma can make going through pelvic floor physical therapy certainly much more distressing as well. So this is an area that needs much more research. And so we're really getting at why is this important. Why is it valuable for us as clinicians to be aware of trauma in the GI setting? So there's multiple reasons, and I'll touch base on a number of these as we go along. But one is that we are aware over 30 years of research that history of trauma can actually increase likelihood of people experiencing a number of different GI symptoms and GI related disorders. So there's a number of studies that actually look at increased abdominal pain, risk of pelvic floor problems, and also heightened discomfort when undergoing gastroenterology procedures. So now we're going to shift gears a little bit and look more specifically at medical trauma. So here is a definition from Hall and Hall, and I just wanted to break this down a little bit. So medical trauma occurs from direct contact with the medical setting, and it can develop through a number of different complex interactions between the patient and staff, the environment itself, and the procedures themselves. And so there are a number of different things in the interaction with the medical environment that can contribute to medical trauma. And the next slide will go into that in more detail. There are a couple of different types of iatrogenic psychological harm. So what the first is primary harm. So this is really harm specifically caused by that interaction with the medical setting. And then we have secondary harm, and in this case we're thinking about people who are coming in with a prior trauma history that through that encounter in the medical environment are re-traumatized due to something that happened in the environment. And so kind of one thing to think about here is that I'm going to be talking in a minute about trauma-informed care specifically, and a lot of the recommendations that come out of the trauma-informed care literature are based on what we know about what can make people who have a history of a prior trauma more comfortable. So it really is the work with them that has helped to develop trauma-informed principles, but as we think about some of these principles that we'll be talking about, it is also valuable to remember that by incorporating these principles we are not only creating a safer space for the people who are already coming in with a history of trauma, but in doing so we're also reducing the risk of causing primary harm as well. So here's a look at some of the factors that can contribute to medical post-traumatic stress. So some of those include surgeries, in particular urgent surgeries or surgeries that might result in additional complications like the need for an ostomy or procedures where maybe the patient didn't have enough time to prepare to get, you know, emotionally prepared for that surgery, difficult or prolonged hospitalizations, having to expose one's body parts to strangers, and in doing so also having to undergo uncomfortable procedures, unanticipated medical complications, uncontrolled pain, and then negative or dismissive interactions with the medical system. So we know that the GI setting is just due to the nature of the sensitive procedures and the type of work that we do is kind of a high-risk setting for causing iatrogenic psychological harm. We also know that patients who have a history of trauma are also more likely to avoid undergoing sensitive procedures such as colonoscopy and rectal manometry and other procedures such as those. And so this really does help to build the case for why we should all be thinking about incorporating trauma-informed principles in our practice. So what does trauma-informed care mean? What are we actually talking about here? So this is one of many definitions of trauma-informed care. So in general it's a holistic approach to health care that fosters understanding and thoughtful responses to individuals who have experienced trauma in their lives and is designed to help support their resilience and self-efficacy. Really, really important to note that trauma-informed care is not just about the gastroenterologist or the endoscopist. It's really about everyone who comes into contact with that patient. And so another reason why this matters, another reason why we should care about trauma-informed care, is that not only is implementing these procedures more likely to, or I should say is more likely to reduce risk of causing harm, but by incorporating these principles we are also cultivating an opportunity for patients to have new experiences with their medical team that can be actually healing on their recovery from trauma. So a patient that has had previous negative experiences with a medical provider that comes in and meets you and where you are providing an environment that feels safe, where they feel listened to, where their concerns about procedures or anything else that they might be concerned about are taken seriously, is one step closer to helping that patient realize that not everyone is going to treat them the way that prior a person may have may have done so. So we can actually be a part of the healing team. So let's get more into some specific strategies that we can incorporate. So we've broken this down pre-procedure during and post-procedure. So let's start by going over trauma screening. So this is probably one of the biggest questions that often comes up as it relates to trauma, is should we screen and if so how do we screen? And as we look through the literature over the past 30 years, there's been some changes, there's some things that haven't changed, but there have been some changes particularly in terms of recommendations. So just wanted to highlight a couple things from this data. So as you can see, overall we have kind of a varying degree of providers who have said that they screen regularly for, in some cases, abuse or trauma. And there's a large percent of providers who did not say that they screened for trauma. You can also see that they're pretty consistently, and we see this in other research as well, that providers are more likely to screen for trauma in particular populations. So more likely to screen and for female patients, also more likely to screen based on particular GI diagnoses like IBS. And there are other factors that they might consider as well. So for example, in the 2019 study that we did, it was just a pilot study of our providers at Michigan Medicine, we asked them some qualitative questions about what do you think about when you decide whether or not to screen for trauma. And some of the things that came up there were, you know, what we just discussed, female gender, particular types of diagnoses, but also patient behavior. So is the patient behaving in a way that appears to be anxious? Do they seem uncomfortable? Do they maybe see I'm uncomfortable with someone in the room with them, like a partner that might be with them or a parent? History of mental health in the chart, so that can bias us. It can both give us feedback, but it also can bias us in terms of who to screen for. And so there is a movement now to move away from prior recommendations, and there were prior recommendations that said we actually don't necessarily need to screen for everyone that might not be relevant to them, these are particular populations we might want to think about that with, to now the movement is more towards we should really think about screening for anyone in our practice, particularly before they undergo a sensitive procedure. So just making this standard of care instead of really picking apart who we might screen for. So how do we do that? How do we bring up this conversation in the context of everything else that you are trying to do in your 15 to 30 minute appointments. So this is just an example of some language you might use. I would highly recommend tailoring this to your own tone and your own language that feels authentic to you. But I did want to highlight a couple of details in this screening language that we provided. So the first is how we open, how we bring this conversation up. So we've written this as, as you may know, many individuals have experienced difficult or traumatic experiences in the past, including history of abuse and other types of trauma. And I'm wondering if you've ever experienced anything that may have been traumatic or upsetting that might make this procedure more uncomfortable or distressing. So the rationale for starting this off with many people have experienced traumatic experiences is that rather than implying that this person has done something or has conveyed something that makes me worry about you, what we're saying is we are aware that this happens to a lot of people. And we're also aware that this environment can be stressful, especially for those folks, but really for anyone. And so I just wanted to check to see if there's anything that you may have experienced that might make undergoing this exam or this procedure uncomfortable. So it really just helps to kind of level set why we are bringing this up in the context of everything else that we might be doing. Another important point here is that it is not the gastroenterologist's responsibility to gather detailed information about a patient's trauma history if they were to say, yeah, there's something, but I don't really want to talk about it. And in fact, in many environments, most likely it's probably not helpful to ask a lot of personal questions in that setting unless you have a particular relationship with that patient where that would actually feel appropriate. So if, for example, a patient were to say, yes, there is something, but I would rather not go into details, that's really an opportunity for us to say that is absolutely OK. You don't have to share anything you don't wish to. What I would like to do is just work together to figure out what we can do to help make this experience more comfortable for you. There's some strategies we can try. And I'm much more focused on just trying to see how we can help you feel comfortable. This can also help with any discomfort that a provider might have about how do I personally deal with the emotional content that comes from trauma disclosure. So communication and consent are some key elements of trauma-informed care. Properly communicating about procedure plan, what's going to happen, allowing time for the patient to ask questions, and validating or discussing those concerns can really help a patient feel more in control of their body and what's happening to them. So if we think about patients who have experienced trauma in the past, a key factor in really most types of trauma is loss of control. And so by really feeling like they understand what's going to happen, that you're going to be checking in with them to make sure that they're feeling comfortable, this now helps to shift some of that control and agency back to them. And that can be very helpful. Also very important to obtain consent before beginning a procedure. And also at any point in the procedure where you might be shifting your area of focus. So if you're going to be examining one area and then you're going to shift to examining another area, really helpful to just pause to say, hey, we've finished up with this examination. Now I'm going to move on to this area. Are you OK with me proceeding? So that's a quick way to just check in and make sure that patient isn't surprised about the change in that examination approach. And then really valuable to create a safe environment. And there's a number of different ways that we can do this. So thinking about the information that is posted both on our websites. It can be just general information to say we really value your comfort and safety. These are some of the things we do to help you feel safe. Also information that's available in the exam rooms to let patients know that if they ever feel uncomfortable, to please bring this up with staff that we really care about. We care about your safety and comfort. We also want to think about how the room is oriented. So we know that many patients prefer to have doors and examination tables facing, I'm sorry, tables and examination tables or chairs, sorry, I can't talk, facing the door. And the reason for that is that many patients prefer to be able to know who's coming in and not being surprised by somebody coming in behind them and being startled. And then also the opportunity to accept or decline a chaperone. Very aware that there are a number of situations in the pediatric population or with other vulnerable populations where a chaperone might be required. And so there can be some nuanced conversations around that. If a patient were to say that they did not feel comfortable having, say, a nurse come in or someone else in that environment, if a patient were to decline, rather than just saying, you know, I'm just required to have a chaperone, what I would recommend is continue the conversation, provide information about why that is either required or why you would feel more comfortable having a chaperone present. And then you can also work with the patient to see if maybe it would be appropriate for someone else, maybe that they know, to serve as a chaperone in that context. But the bottom line is let's not just trudge through saying, well, I'm required to have a chaperone present. Work together with the patient to find a plan that works for both. So now looking towards during the procedure. So as I mentioned, always important to obtain ongoing consent if there were to be any changes in the procedure. And then another important element here is monitoring for signs of distress or dissociation. So dissociation is a coping mechanism for distress. And it's very commonly experienced by trauma survivors. But it also can happen for anyone just experiencing high anxiety or under high stress situation. So any of us may have experienced symptoms of dissociation at some point in our life. And it can have benefits, too. So it's not inherently bad. But it also can help make people feel out of control. And so there's different ways that people can experience dissociation. Depersonalization, or feeling disconnected from themselves, or feeling like they're watching or observing themselves. Derealization, where if the world doesn't feel real to them, they feel this detached or disconnected from the world itself. Memory fragmentation, emotional numbing. And the one that you're probably most likely to spot visually would be a patient who seems really zoned out or checked out or maybe you're asking them questions. And maybe they'll mumble like a yes or no. But they really don't seem very connected to what's happening in the room. So there are different things that we can do here. So asking direct questions that require the patient to answer more than a yes or no can kind of help bring them back to the present, bring them back into their bodies. You can also discuss nonverbal cues. So for some patients that have expressed to you, I do have a history of trauma. This is what tends to happen to me. And I tend to not be able to talk. There's been some research in pelvic floor physical therapy that has found that you can discuss in advance, hey, if you need to lift your finger or if any sort of nonverbal cue to say, can we pause? Can we stop here? These are some ways that we can help patients communicate when their body is and their minds are kind of blackened down. And also just provider flexibility. So if you're detecting that this patient's really not doing well, maybe they're trying because they really feel like I need to just kind of push myself through this. But you're realizing this is getting really difficult for the patient. If any aspects of that examination or procedure are not absolutely necessary, the provider might decide that we're going to hold on that and maybe revisit that at another time. And then finally, post-procedure. So really valuable to debrief with the patient. I know many providers do this already in terms of what actually happened from a medical perspective. This is the procedure that you have. This is what we found. These are next steps. This is also an opportunity to debrief about the patient experience, how that was for them, if there was anything, just saying we really are interested in your feedback. Was there anything about that experience that was uncomfortable? Or is there anything we could have done differently? This is a really great way to just help build patient satisfaction in general is when providers express interest in improving the patient experience. This also provides an opportunity for repair. So if something did happen, if we missed something, and it happens. Nobody does this perfectly. If they missed, if they were in a lot of pain and we missed it, this provides an opportunity to address that, acknowledge that, apologize. And that can have a tremendous effect on whether or not the patient perceives this as an ongoing trauma or if it becomes a situation that was uncomfortable to them but because the team really took it seriously, the patient is able to move forward from that. And it doesn't have to negatively impact them going forward. And then for those patients that indicate that they would benefit from additional mental health support, or if you pick up on that, providing additional mental health referrals. So I'm going to transition over to Dr. Real. She's going to talk about some case examples. Thank you, Dr. Jogielski. I always learn so much and get these reminders when she presents on trauma-informed care. So we're going to cover three different case examples. And then, as we said, we want to save some time for questions. So be thinking about that if you want to pick our brains here. But we're going to start with our first example with Maria, a 42-year-old female with a history of irritable bowel syndrome and anxiety. She's scheduled for a colonoscopy and related to these persistent bowel changes. So in this case, we want to be thinking about how common is IBS, right? So about 1 in 10, 1 in 11 is the statistics. How many patients with IBS have anxiety between 30% to 40%? So Maria is a very common patient that the majority of us have seen in clinic. And so approaching Maria, we're going to be doing some trauma screening. So this is kind of the ideal experience that a patient might receive. During the intake process, a nurse may say something along the lines of, have you ever had any past medical experiences that were particularly distressing? Or we can go back to some of the language that Dr. Jogielski gave us earlier. Have you ever experienced anything that you identify as traumatic or distressing? And when you throw in that you consider, again, it gives patients the opportunity to, you know, sometimes we'll have patients that say, well, I wasn't in war. Or, you know, but there was this experience that I had when I was in college. And I love giving patients that open door to say, I'm not here to judge what you experience as traumatic. It's most important that we are aware and that you have the opportunity to disclose that. And so, you know, helping to make Maria feel more comfortable when and if she had a negative experience or a traumatic experience. So she shares that she did have a difficult endoscopy years ago. And she felt rushed and unheard. And this led to increased anxiety about some of her procedures. And so, again, just in that initial trauma screening, we're learning a lot about Maria. And number one, we're thankful that she's in our office with us willing to go through a procedure. So we want to then proceed through our experiences with her communicating and obtaining that initial informed consent. And this is an opportunity, again, where we're thinking about our posture, our tone. Sitting at eye level with Maria and explaining the colonoscopy process in very clear, patient-focused language. Helping to make sure that she understands why she's having that colonoscopy. What are the risks and the benefits? And giving her an opportunity to both express any concerns that she may have or asking questions. And then signing that informed consent. Answering questions and validating concerns. Again, this is where we know our nursing staff. We know our techs are a part of this process. And you may not be always the person that's receiving that informed consent up front. So this is an opportunity to be talking about our staff and that we are all responsible for providing trauma-informed care. Giving her the opportunity to talk about any potential pain that she may be experiencing and whether she might be flashing back to that first procedure that she felt uncomfortable in. And then we want to think about cultivating this trauma-informed environment. So as I was saying, that our staff are involved in helping to make sure that Maria feels in control by offering some of the choices. So music in the room. Allowing her to have a support person. What does it look like as she's preparing for this procedure? And then after. So coming if they're using anesthetic. Making sure that there's a calm tone, a warm voice. And not rushing in our interactions with a patient that previously felt invalidated and rushed in the past. And then we can really be checking in. How are you doing, Maria? Are you comfortable? Is there anything we can do to make you more comfortable? We're going to be doing this now. Kind of verbalizing and expressing what she can expect before it's actually happening to her. This is certainly going to reinforce that you care about her safety. You care about her having a sense of autonomy in the room and that she is very well cared for. So I think that even if Maria had not experienced a negative experience in the past, this is how we want to approach most of our patients. Really, this can be kind of the gold standard of care for a patient. So moving on to case example number two. Somebody that's going through their procedure. This patient, James, is a 35-year-old male with a history of Crohn's disease. And it's documented in the medical chart that he has medical post-traumatic stress disorder. And he's going to be having a sigmoidoscopy to assess for current disease activity. So with this patient, again, we're thinking about how we can make him most comfortable and approach him from a trauma-informed perspective, obtaining ongoing consent with this patient. So as the procedure begins, the gastroenterologist, as well as staff, can explain each step in a calm and reassuring voice. And so this is also, I think, practicing this. When you're talking with your trainees and your fellows, I always like to say, trauma-informed care is really a practice and a skill. And so as you're working on your tone and how you engage with a patient, how you look at them in the eye, how you get down at their level, how you're making sure that your stance in a room is open and not feeling as though you're closing the patient in is all important. And so then you might say, James, I'm about to introduce the scope. You may feel some pressure, but if you need to take a break, let me know. James may be very aware, or he may be in a twilight, or he may even be under anesthetic. But I think it's still important to verbalize what you're doing, even if you think a patient is completely under the anesthetic. Then monitoring for signs of distress or dissociation. So midway through this procedure, the nurse notices that James has become very quiet and is staring at the ceiling. His breathing has become very shallow. And you, all of you that are becoming so well aware of these things, you might recognize that this is a potential sign for dissociation. And so the nurse is going to gently place her hands near his arm with consent. So James, I'm about to touch your arm with my hand and speaks in a very soothing tone to just give that reassurance. James, you're doing really well. Can you take a deep breath with me? Would you like to pause? And again, thinking that it might take some time for the brain to kind of be making those words come about and giving him some time. And so James blinks, takes a breath, and responds with, yes, a quick break could be helpful. If you don't get a response, this may be a good opportunity to say, James, if you're with me, let's kind of, if you need a break, go ahead and raise one finger with me or squeeze my hand if you'd like to squeeze my hand. And so when James recognizes he would like a break or verbalizes he needs a break, the team can pause briefly, just allowing him in those moments to regain a sense of control before proceeding. Now, I know we're talking about this at length here, but all of this can happen pretty quickly. So in terms of we know busy schedules and there's a patient and another patient and another patient and another patient, but these brief pauses are so beneficial for the patient and can really, as we know, a lot of times gastroenterology patient-provider relationships are long-term. You're going to be scoping that person again at some point or seeing them in your clinic. And so building this therapeutic relationship where the patient feels heard and validated is so important. And so in case number three, this is a patient post-procedure. Sarah is a 29-year-old female with a history of ulcerative colitis and three prior hospitalizations due to severe flare-ups. She's just undergone an upper endoscopy to evaluate her ongoing symptoms. And she's previously canceled this upper endoscopy two times, and she's showing up late for the procedure. And we know that at times these patients can be perceived as difficult to work with or really disrupts the flow of your own clinic, and it can become very easy to be frustrated with a patient who is no-showing. But this is our opportunity to, again, pause and dig a little deeper into what may be going on with a patient like Sarah. So Sarah has undergone her procedure. She's made it. She came. She was late, but she made it through. And the gastroenterologist and nurse are beside her bedside, and they're sitting, maintaining a calm and reassuring presence and allowing that conversation. Sarah, you did really well during the procedure. So we're offering kindness to this patient. We were able to examine your esophagus and your stomach thoroughly. And do you have any immediate questions right now? And in this case, Sarah, while still groggy, asked, did you find anything bad? And we're probably thinking, this is a patient that may be thinking back to prior hospitalizations. What could be in the future? And as a provider, you're starting to explain. We saw some mild inflammation, but nothing alarming. We took small biopsies to get more information. And we'll discuss those next steps once we have the results. And we know that results can sometimes take a little bit of time. And for somebody that has increased anxiety, depression, or trauma, that wait can be a long wait. And also, they can totally forget. And so this would certainly be a good opportunity to provide that written summary very clearly before discharge. And so we hand Sarah a printed summary reviewing the key findings. What are the next steps? What are any medication instructions? So that way, she has some time to process that experience process. I mean, even just going through the procedure can take patients. It can exhaust them, quite honestly. And so stating, this is the details of today's procedure, what to expect over the next 24 hours, very clearly laying out who to contact if they have any concerns. And then, as Dr. Jagielski will share, we'll give some referral resources for all of you today. But we want to make sure that we provide any trauma-informed referrals, if needed. So Sarah mentions to us that she's feeling very anxious about waiting for those biopsy results, and that generally, she's been struggling just with any idea of living with this disease. And the fact that she's going to likely require additional medical procedures and possible hospitalizations over the course of her life, and she's a young woman. And so the nurse can validate these feelings, offering support. And as GI psychologists, it's certainly an opportunity to engage this patient with somebody like ourselves. But if the patient is in more need of more general anxiety, more trauma-informed work, we have that available as well. So just communicating to the patient that we have resources for you available. And it's very understandable to have many of the feelings that you're experiencing, living with a chronic disease. And so informing the patient that we have a psychologist, a part of our team, that the integrative model is so helpful with these patients to help them understand that they're not, you know, your symptoms are in your head, or that this is uncommon. But we have psychologists available to help with the complexities of navigating life with IBD and asking if that patient would like a referral. So at this point, we're going to shift back to Dr. Jougalski and let her take us on home in a couple minutes here. So I just wanted to wrap up here with a couple of just take-home points. So first, some of the common misconceptions with trauma-informed care. So first, trauma-informed care is not the responsibility of one provider. Really, all members of the medical system can contribute to providing an environment that is trauma-informed. Trauma-informed care is also not the same thing as trauma-focused treatment. So trauma-focused treatment is really provided by trained mental health professionals. And you, as a provider, should not feel responsible for providing treatment if a patient were to experience anything that they consider to be traumatic. It's really our role in the medical setting to be creating the environment that feels safe for that patient. But it is also important to know you do not need to practice or provide care that's kind of outside of your scope of practice there. Again, as I mentioned, you do not need to know the details of a patient's traumatic experience in order to create an environment that is trauma-informed. And also, trauma-informed care is not just for patients with PTSD. It is really designed to help to create a safe environment for all patients. So in summary, patients with GI complaints are more likely to report a history of trauma. Trauma can affect any patient, regardless of gender, diagnoses, mental health history, or background. It's really valuable to try to avoid assumptions based on appearance or disclosure. We also know that trauma can exacerbate GI symptoms and can negatively influence a patient's ability or willingness to engage in care, attend appointments, or undergo procedures. Routine trauma screening, especially before invasive or intimate procedures, should be considered a key component of patient-centered care. And then finally, incorporating trauma-informed principles into your practice can help to reduce both primary and secondary iatrogenic trauma, as well as improve patient satisfaction. And then finally, Dr. Real mentioned this. So we had talked about how post-procedure, one of the steps that we might want to incorporate are providing mental health support. And I am very aware that many times, it can be difficult to find trauma-informed providers or GI psychologists. And we also have a few in number. And so here are some ideas for how you might go about finding trauma-informed providers in your area. And this is really going to vary from institution to institution. So my first recommendation would be to see what is available in your institution. So if you're at an academic medical center, there most likely are mental health professionals around. And so just kind of reaching out to see what is available. Another way that we often will find other mental health providers if we are providing referrals is through the website Psychology Today. And that is a free resource that you can just find online. And you can look specifically for your area. You can look based on insurance of the patient. And there's also specific options to select providers who focus on trauma. What I recommend in those environments, if you're able to do so, is to find a couple of people that look like they might be good referral sources. Just reach out to them and see about developing a collaborative relationships and see if they're open to receiving referrals from you. That's a good way. That's a good way to kind of build up your own team, even if your own practice does not have an embedded psychologist. There is a virtual practice called GI psychology. Many of those practitioners, I believe, are here at the conference this year. And they are, so all of their care is provided virtually. And I believe that there are providers in most states, if not all states. And they do have some, so they have providers there that specialize in GI psychology practices, just like myself and Dr. Real. And they also have people that are able to provide trauma-informed care as well. And then another option is to encourage the patient to check with providers within their insurance network so that the insurance providers can send a list of people that are in network as well. And then for patients that maybe are not needing trauma-specific treatment but might benefit from working with someone like Dr. Real and myself, you see here on the right the Rome GI psychology directory. So that is a way that you can find anyone that specializes in GI psych. So just entering your city or zip code, and it'll kind of bring whoever's closest to you. So with that, we will open up for any questions. Thank you all. Thank you. My name is Susan Lusak. I'm in Cornell, New York. So over the past couple of decades, I've been taking care of a lot of patients with Irritable Bowel Syndrome. And we as gastroenterologists are not really trained to obtain trauma history. But I kind of have learned on my own as I have been going through this, because I have learned from Dr. Osman that it's important to ask that history, because it kind of tells you a little bit about when there is a history of trauma, that these are patients that tend to be a little bit harder to treat. They are more resistant, and they need different care. And you may need to approach it, not just look at gut-related therapies, but obviously psychological or even psychopharmacological treatments. So one of the things that I have found is that when I ask for a trauma history, and it took me several years to sort of figure this out, is that to ask whether they've had difficult moments in their lives. And some people will say yes, and then they will say they don't want to talk about it, just as you mentioned. But then there are those who actually do want to say something. And I think that as gastroenterologists, we kind of need to, in a way, learn to listen and to provide sort of ear for them to tell you, because some of them do want to tell you. And I think I have found that if they are willing to share, to listen, and to kind of be prepared to ask appropriate follow-up questions. And one of the things that I have found helpful was to say, how did this end? How did the trauma end? So there's like one, if it ends up where a mother's boyfriend abused the daughter, and the mother wouldn't break up with the boyfriend, that would be one outcome. And if the mother would break up with the boyfriend, then that's a different outcome, right? And depending upon how that kind of ended up, then when there was a resolution, there was then kind of a better outcome, in a sense. And certainly providing sort of say, as you had this discussion, you can say, I'm sorry this has happened to you. So kind of provide, in a way, empathy. And then ask them, how do you think we should go forward? And sort of really kind of leave it to that. And I have found that this approach has actually been quite helpful. And it's pretty simple and straightforward. I'm not spending a lot of time with them, but I'm just really listening. And it doesn't have to be a long saga. And they usually don't really go into tremendous details, but enough to kind of tell you a little bit of a sense. And I have found that to be helpful. The other thing I just would like to say is that when a patient is avoiding surgery, let's say colonoscopy, and they are now 60 years old, and they should have had colonoscopy because they have a family history of colon cancer, and they should have had colonoscopy at the age of 40, let's say, or now even 35. So then you can ask why. And then sometimes the issues of trauma come up. And then this is also when you can ask them, how do you think we should handle this? Is there something specific about that is a problem for you? And how do we deal with it? So I ask them to tell me what they want. I don't tell them what they want. Absolutely. So I don't know. Thank you. Thank you for sharing that. There was so much there that I really wanted to touch on. For sake of time, I won't. But I just want to acknowledge, one, the work you have put in to figure out what works for you. And I know it can take some time to really figure out, how do I bring this up? How do I address this? And it sounds like you've really figured out a lot. There's still more to learn. And also, I really just wanted to highlight your point there, that when it comes to a next step, I don't think I mentioned this, but I meant to. When it comes to, for example, even thinking about if someone might be interested in mental health referrals, it tends to go much better if phrased as a question, to say, I really like the way that you said that. And also, it might be, we do have providers within our institution that may be able to help you. Is that something you would be interested in? Sometimes at the time, especially if the patient was not expecting to talk about this that day, and they're kind of rattled a little bit, they might say no. They might say, no, I don't want that. And then you could say, that is totally OK. If you ever change your mind, please let me know. I'd be happy to do that. So that allows them to come to them on their terms. And I think that's a lot of what you're getting at, is when you say, what do you think would be helpful? It's really bringing, it's not a provider saying, I think you should do this. It's really inviting them in. That gives them more control. So thank you. Well, thank you for a wonderful talk. It really is next generation care. The nurses at the hospital are very good at this kind of thing, although obviously, I think this is a way to grow that they can definitely improve with. Our office doesn't do any of this at all. And I am embarrassed by it. It's almost like a wake up call. I do a soft gel motility and a rectal manometry and this kind of thing. And general gastroenterology with a lot of colonoscopy. And this is not something that our office addresses at all in the 15 minute visit that includes everything about this person. And I know this is really important. So do you have any ideas, like the level of training of someone that we would have to acquire or bring on board? What level of training should I ask them to pursue for someone who would really focus on this kind of concern and care and handholding? Really, I mean, this is really important. So what level of provider do you think would be? Are you thinking about more so like nursing staff? Or you think about bringing on a mental health provider in this area? I mean, I don't know. I'm asking really kind of, we have a general gastro practice. We have six, and they're going to expand to nine. So it's going to become more of a problem, not less of a problem. And we certainly don't spend any time talking about trauma before we do these procedures that really are clearly, that's a big issue. I'm just wondering, would a psychologist or would a registered nurse, certainly would a registered nurse be able to address these things? I'm just wondering, I'm trying to approach it with administration, who wants to save every dime. All we have is medical assistance. We literally have four medical assistants, and they're running around like chickens without heads. And I'm really kind of trying to think of a registered nurse, because certainly an MA is not going to be the one to appreciate these. Is there a trauma-informed certification that we get? There are. So there's a number of different programs out there. There's not one specifically that I would recommend. But there are, and there are programs that are targeted more towards nurses to get trauma-informed certification. Certainly there are programs for various types of mental health providers out there. There are some for physicians. I actually haven't located them, but I have heard that some of the people that filled out our survey have actually completed some certification. So that is an option. I would say, and Megan, I'll see your feedback here, too, but I would say I don't think that you need to go into this thinking that we can't get started making any changes until we have somebody who's an expert. You could just even take some of this information back to your team and just say, with what we have, with what we have, are there ways that we could start incorporating some of these principles? It may be beneficial to bring in a trauma, and maybe if there's a nurse who is really interested in getting some additional training, those options are out there. There's online trainings. There's in-person trainings. But I would say just don't assume that you can't make any modifications until you have an expert on your team, because most practices don't. Most practices don't have a trauma-informed expert on their team. Does that, I don't know, Megan, I'll get your thoughts here. Yeah, I just think that coming back after DDW is a great time where we all feel refreshed to say, you know, I've got some really great ideas that I want to bring into our practice. And I appreciate your humility. And this is the reality, that most of us are not trauma-informed from a trained perspective, but you're sitting here in the room interested. And so kind of bringing that lens back to say, hey, you know, how can we do better by our patients? And it could start with a screening question that gets incorporated into your workflow. And the question can be as straightforward as, you know, have you experienced any trauma in your life? Yes or no. The key, though, is that you're going to have somebody that looks at that question. And then that way you're able to go into the room, just even having that information, that a patient disclosed that to say, we want to make this experience, you know, as comfortable as possible. How might we do that for you? Some patients might say, I'm good. Others might say, you know, I've had this experience, and when this was available to me, that really helped me. So I think just having a very open conversation with your teams around, you know, trauma-informed care, again, from a website perspective, that we provide collaborative, thoughtful care for your endoscopy experience. Patients appreciate that. They're looking for that language. You can ask your team, like, ask your team to go around the lab and ask everybody, how many girls and how many boys or how many women and men do you think have sexual trauma? See if anybody's really influenced. Yeah. Right there, we'll all figure it out. Yeah. How many boys and how many women. Just asking the question of intake, right? The extent of success or not. And we just, you know, we actually, as a result of one of the things, one of the presentations, we did at Michigan, ended up, one of our directors decided to add in our existing review of systems questionnaire under mental health. They just added a history of trauma, and we just, you know, put abuse, combat trauma, medical trauma. So we made it broader, and it was just there. It was an option that a patient could endorse. If they didn't want to, they didn't have to. But then, you know, that now just appears in the review of systems. We haven't heard any complaints about that from the patients. And it gives you an opportunity when you're going in to meet that patient to just know that's a part of their history. I do think it is important if a patient endorses a history of trauma, especially on the questionnaire, that we don't assume that that's necessarily impacting the patient now. I think sometimes, especially when we're a little bit more nervous in this area, we can look at that and think, oh, OK, this person's probably going to be very anxious. Or we can have assumptions. It is possible that person's already been through therapy. It's possible that the person got good support at the time, and it was a moment for them. It was big for them, but they're not. And so if that could take a little bit of pressure off to know that even patients that endorse a history of trauma may come in, as Dr. Riehl said, and say, you know, for this experience, I'm good. I feel safe here. Thank you for that question. Thank you.

trauma-informed care

gastrointestinal health

IBS

IBD

patient-centered approach

medical trauma

trauma screening

healthcare setting

patient satisfaction

mental health providers