COVID-19 and the stressors it is placing on individuals’ physical, emotional, and financial wellbeing create a new imperative for health care systems to look to trauma-informed care to support both patients and frontline workers. To learn more about how health care providers are using trauma-informed approaches to care in the current environment, the Center for Health Care Strategies (CHCS) recently spoke with Edward Machtinger, MD, professor of medicine and director of the Women’s HIV Program and Center to Advance Trauma-Informed Health Care at the University of California, San Francisco (UCSF).
“Dr. Eddy”, as his patients often call him, is a long-time champion for trauma-informed primary care. During our interview, Dr. Machtinger shared how his clinic is managing the impact of COVID-19, how trauma-informed care has been essential in guiding the health center’s response to the pandemic for both patients and staff, and what he and his team have learned along the way.
Q: Your clinic serves women living with HIV, many of whom are impacted by substance use disorder, homelessness, and trauma. How are you seeing this pandemic play out with this specific population given their array of needs?
We are trying to connect with our patients about their anxiety, living situation, and management of chronic illnesses so that we can help buffer the impact of this trauma on their bodies and minds, which were already heavily impacted by trauma and therefore more susceptible.
A: My framework for thinking about this is that there are two pandemics — one caused by the virus and the other caused by the trauma and stress associated with the pandemic. COVID-19 is dangerous for my patients. Women living with HIV have very high rates of cigarette smoking, stimulant use including crack cocaine, and chronic health conditions such as obesity and diabetes, and they experience these conditions disproportionately due to the high rates of trauma in this population. Our clinic cares for a very traumatized population — predominantly low income, predominantly people of color. Due to systemic racial and health inequities, they are the exact population that is disproportionately infected with and dying from COVID-19. So, we are nervous about the safety of our patients from this particular viral pandemic. Our first focus, therefore, has been on engaging them to better understand how we can partner with them to help prevent COVID-19 infection, and then providing them with access to our health care services, our testing, and our hospital if they are showing symptoms of infection.
Our concurrent focus — which is probably even more important — is on the trauma and stress associated with COVID-19. There is a known phenomenon after disasters of increased morbidity and mortality, depression, anxiety, suicide, substance use, overdose, violence, heart attacks, strokes, etc. There is a predictable second wave of death that occurs after exposure to a mass trauma, and we are beginning to experience something similar with COVID-19. We are trying to connect with our patients about their anxiety, living situation, and management of chronic illnesses so that we can help buffer the impact of this trauma on their bodies and minds, which were already heavily impacted by trauma and therefore more susceptible. With that being said, I think some of our patients are handling this well because they are resilient and have often dealt with mountains of risk and chaos throughout their lives and are stronger in many ways from it.
Q: How are you adapting the high-intensity services you provide and keeping patients connected to their care in the current environment?
A: Our attention is on proactively identifying and engaging patients who are most at risk of getting sick and dying both from the immediate effects of the virus and the more long-term, stress-related effects of the pandemic. First, we identify and risk stratify these patients, which, in itself is a fairly radical innovation to the way care is provided. Then we proactively outreach to them on a regular basis based on their risk of illness or death from COVID-19 or COVID-19-related stress, scheduling virtual appointments with them with a frequency based on their risk. How we engage patients during these encounters is where trauma-informed principles — trust, transparency, collaboration, empowerment, safety, among others — are at play. Our role in these encounters is to normalize and de-stigmatize various feelings like fear and coping behaviors like substance use. We are trying to create an encounter where people feel safe enough to reveal themselves, which is a central trauma-informed principle. Most often, what people reveal is far more important and risky to their health and wellbeing than what our agenda was coming into that meeting. That’s the practice that is most important, because you can’t refer anybody to a domestic violence hotline if they’re not going to disclose to you that they’re in a violent relationship. Unless you really de-stigmatize and normalize that, they won’t disclose to you and you won’t have an opportunity to help them.
Q: How has the robust work you have done in trauma-informed care prepared you in responding to the pandemic?
The permission to be human and to understand that shared connection and vulnerability and presence is a therapy unto itself. It’s not always sufficient, but it’s a necessary foundation and something that is very intuitive to people right now. And I think when you name it and give people the permission to behave that way, it’s very liberating.
A: We have been researching for almost a decade about the impact of trauma on health and behavior and ways to integrate healing responses to trauma into primary medical care. And now we’re all living through a mass trauma, the likes of which none of us have seen before. People are increasingly recognizing the impact of stress and trauma on someone’s ability to stay strong and healthy and to prevent disease. I think trauma-informed care is getting so much more traction in the health sector because doctors and nurses who are engaging patients in the current environment are realizing that this is a shared experience. They are realizing, first hand, that shared connection and shared vulnerability with patients is therapeutic. The permission to be human and to understand that shared connection and vulnerability and presence is a therapy unto itself. It’s not always sufficient, but it’s a necessary foundation and something that is very intuitive to people right now. And I think when you name it and give people the permission to behave that way, it’s very liberating.
Our ability to connect with people who are often very different than we are in terms of their income or life experience is so powerful. Many clinicians are having panic attacks themselves, struggling with substance use, or are being driven insane by their kids during this time, and that breeds a type of empathy that I think will allow trauma-informed care and these principles to resonate more deeply with clinicians than they ever have before. It also highlights the need to support each other as providers and staff right now.
Q: How are you supporting your staff and their wellbeing during this time?
This transparency requires discipline and practice to get right; in truth, I am still learning how to share my feelings and details about the finances of our program in ways that I think are helpful.
A: Shared vulnerability and transparency are really important. Being as absolutely transparent as you can about your own emotional experience, about any financial threats to the clinic, the unknowns…people are scared about their jobs, their physical health, catching the virus from patients. So just being really open about sharing those concerns and collaborating around addressing those concerns so that you can solicit as many ideas as possible from the staff about how to be safe, who needs to be seen, etc. This transparency requires discipline and practice to get right; in truth, I am still learning how to share my feelings and details about the finances of our program in ways that I think are helpful. I’ve also been reading a lot about racial justice and how to become anti-racist in my language and actions. This has helped me understand how to acknowledge the moment without inadvertently putting people on the spot.
Q: Are you learning anything about your patients, staff, or the way that you deliver care that you’ll want to hold on to or that will change the way that you practice in the future?
A: The access divide between people who are really adept at using video chat and the people who aren’t is extreme. We’ve managed to get almost every one of our patients on a video visit, and we’ve been able to do that because we have proactive social work staff. We surveyed all of our patients to determine who had access to Zoom, and if so, what barriers they had accessing it (e.g., knowledge, hardware, Internet, etc.). We then educated those who had smartphones but were struggling with the Zoom app. For patients without smartphones (which were not that many), we purchased very inexpensive (i.e., $50 dollar) tablets for them using funds donated to the clinic.
I’ve also noticed that video encounters can be really intimate and effective. For example, a 15-minute video encounter with a patient can feel like a really long time, compared to being seen in clinic when there is so much chaos about getting to clinic, being in clinic, seeing other people in clinic, and being put through our institutional stressors. You just Zoom into their living room where they are sitting with their dog or girlfriend or whomever, and you’re just on. Seeing them on a video allows for a much calmer visit. I think we are going to move toward some sort of hybrid approach to in-person and virtual visits for seeing patients in the future – even though we are an extraordinarily high-touch clinic. For us to say video visits are actually going to become a bigger part of our care model is shocking to me. I had been a total technophobe before all of this.