OK, everyone. We're going to go ahead and get started. It's 12:20. My name's Sumner Abraham. I'm one of the new medicine chief residents who help facilitate Grand Rounds throughout the year. And I'm going to have our associate chair for professionalism and diversity, Dr. Preston Reynolds, introduce our speaker. So thanks for being here. So it's a wonderful honor and a joy to invite back Marshall Fleurant. His first time at the UVA was actually in 2000, and he did the Summer Pipeline Program here when he was in college. And we were touring the academic grounds this morning, and he was talking about how enormously impactful that program was in preparing him to apply to medical school. So he's currently assistant professor in medicine at Emory in the Division of General Medicine and Geriatrics in Grady. He received his medical degree from Albert Einstein, and it was actually in the Experimental Social Medicine tract there. It was the first cohort and completed his residency at Thomas Jefferson University Hospital of Philadelphia. He then completed a fellowship in General Medicine at Harvard in an MPH at the Harvard School of Public Health with a focus on Clinical Effectiveness. He's practiced as a clinician educator at Boston University School of Medicine, as well as worked in private practice at Kaiser in Atlanta before going on faculty at Emory. He currently is really as a clinician educator who oversees medical students and residents in the inpatient wards and as a clinical preceptor for students and residents in the Grady Hospital Primary Care Clinic, where he is one of the leads in that clinic. His main interests are improving health access in health disparities, preserving the safety net for the underserved, and strengthening the field of primary care. His publications include a contributed chapter on a book, Tectonic Shifts: Haiti Since the Earthquake, and publications in JAMA, Health Affairs on physician use of registries and incorporation of the electronic health record. He's also published work on the use of Balint groups and academic primary care to improve work-life balance and reduce burnout. He's an active member with the Society of General Internal Medicine. And this year, I've been honored to serve as his mentor for part of the Leadership and Education and Advocacy Health Program, Health Policy Program it's called Leap. And so Marshall and I have been the on the phone, at least monthly, in my mentoring role. And actually, sent me the chapter on from Informed Care to edit. So I said, oh, I need to bring you here to do this as Grand Rounds. He's led the Minorities in Medicine interest group that now has grown into the Commission on Health Equity. And that is a role that he is now going to serve as lead of that group next year. It's interesting. My first experience with Marshall was actually at an SGIM symposium, which he helped design. And I have to say that could hear a pin drop when the symposium opened with videotape narrative SGIM members who had actually experienced trauma themselves at the hands of police brutality. But Marshall was one of the voices in that narrative. And I remember it to this day, because I remember my eyes welling up and tears running down my cheek to think that my own colleagues had experienced trauma as professionals. So with that, I welcome Marshall to share with us his current area of academic work and his own personal experience. [APPLAUSE] Hello. Thank you very much. Thank you for your-- for the invitation today. Can you hear me pretty well? Great. So, first of all, I want to say thank you to UVA again. First, for the MME program, or as an undergraduate, and kind of led me on my way to becoming a doctor today. So thank you UVA for that first time 10 years, 20 years ago. And I'd like to also thank those who made this possible, Mitch Rosner for the diversity series that is going currently. Preston Reynolds, Sumner Abraham. Thank you very much, and Peters Anthony, who is not here right now. I think he's kind of moved on forward. But thank you for that. Tony Burkman, and Judy, and anyone who I forgot. Thank you very much for that. So today we're going to talk about Trauma Informed Care. And a lot of this talk comes from my book chapter. And what I'm going to do is, I have several objectives that we're going to try to go over. We're going to introduce and define Trauma Informed Care. So we're going to kind of define what we're talking about. And then we want to review some case studies on the Trauma Informed Care literature. And then we're going to discuss African-American male responses to trauma. So going a little bit deeper into the book's chapter. And we'll review some examples of trauma informed culturally competent research. | I just have no professional or personal disclosures. So a lot of people ask about how did I get into this topic to begin with. And this is coming from an exhibit called The DO or DIE exhibit at the Carlos Museum at Emory University School of Medicine. So in 2015, Dr. Fahamu Pecou started working on his dictatorial project, his thesis. And in this project, he was kind of disturbed by some images that he saw in the media, on cell phones, and videos of young black men being shot or killed through various events. And he was inspired to start his work on this particular project. So he did some work looking at the Yoruba tradition in Nigeria. And the Yoruba tradition, they have something called the Egungun, and this is part of the Egungun mask and outfit. And basically, it is bringing ancestors back to the village to venerate them, to honor them. And what Dr. Fahamu Pecou, what he did is he made an Americanized version of that, bringing back the names of those who were lost as a way to honor and respect and venerate those who are lost. You know, at the same time, Dr. Pecou did his thesis in 2015, I-- as the Chair of the Minorities in Medicine Interest Group-- started a symposium on the intersection between society and medicine and societal discourse and some tense-- tense topics. Our first symposia was the Population Health Impact of Racial Bias and Social Injustice, an Example of Police Brutality and Black Men on Racism. Now one of the speakers of that talk was Dr. John Rich. He was one of the speakers in that talk. And after he was-- after that particular symposium-- we did several more after that-- but after that particular symposium, we had a discussion. And he asked me, have you ever heard of the ACEs study? And that's basically how I started on this path. And we'll get into that in a moment. So when I'm talking about trauma, I'm not necessarily talking about the trauma that you would get from a car accident, or if you were burned in a fire-- although that itself is incredibly traumatic. What I'm talking about is more of the type of trauma that you might experience from neglect, from abuse, from being in a violent neighborhood, or a household where violence can happen suddenly. Trauma is tough to deal with. And as, providers, it can feel kind of overwhelming. You can feel like this figure cowering on his horse, kind of overwhelmed by having to deal with this on top of all the other things you have to do in your practice, or maybe this Atlas figure, kind of overburdened with everything that you have to do. And then it's taking on trauma at the same time. But one thing I want to point out is that this is a team sport. What I like about this particular field is that it involves-- all these fields have skin in the game, from trauma surgery all the way to internal medicine. And maybe a trauma surgeon might see someone more proximal to the event of trauma, and maybe over in internal medicine, we might see someone more distal to the event of trauma. But it involves-- it's a team sport. So it involves all-- all these fields and almost all ages. So let's talk a little bit about the epidemiology of violence. Unfortunately, it's pretty common. So nearly 31% of men and 26% of-- 31% of women and 26% of men experience internal-- interpersonal violence in their lifetime. In a study by the CBC, looking at the 2013 Youth Behavioral Risk Survey, 10% of boys and 21% of girls have reported physical violence. In this study in the general internal medicine, the past year prevalence of interpersonal violence, a woman seeking primary care, was 19.9%. Now I am right now working in a city hospital-- Grady Memorial Hospital. And I would say that the prevalence of what we see is probably close to this in our internal medicine clinics. And it's not just women alone. 28.5% of men reported being victimized at some point in their lives. So what do we mean when we talk about trauma-informed care? So this is a definition that's from the National Center for Trauma-Informed Care. And it's a program, organization, and system that really realizes, recognizes, responds, and resists. Realizes the widespread impact of trauma and potential plans to recovery. Recognizes the signs and symptoms of trauma in clients, families, and staff. Responds, fully integrates knowledge about trauma and policies, procedures, and practices, and seeks to actively resist re-traumatization. So there's trauma-informed care, the philosophy of trauma-informed care. And there's trauma-informed care, the operationalization of trauma-informed care. We'll get to get into that. So how did we get here? So this is a timeline also from the National Center for Trauma-Informed Care that came out in a brochure in 2012. And they talk about the movement, starting with the Vietnam vets returning from the Vietnam War. And the feminist movement, highlighting more about domestic violence and personal violence. And this led eventually, in the 1980s with the VA Center for National Center-- the VA established the National Center for PTSD. And actually around this time DSM-III included PTSD in their definitions around that same time. So it really brought in this particular focus. In addition, the government authorized the Victims of Crime Act, which gave federal money to states to distribute to states and for states to distribute directly to victims of crime or programs that serve victims of crime. Some federal money started getting thrown into this. In the 1990s, we had some landmark studies that will go into, including the ACEs study. And then in 2000, we have the establishment of the National Center for Trauma-Informed Care, so the beginning of a institution at the NIH level. And now we're getting to the time where professional organizations are really starting to look into this from their own lens. So let's talk about the ACEs study. ACEs means Adverse Childhood Experiences Study. And this is a study to describe the long-term relationship of harmful childhood experiences of dysfunction to medical and social outcomes in adults. So the population was a middle class suburban population. A good amount of this population college educated. And it was done at a primary care clinic in San Diego at Kaiser Permanente. So this was a effort between Kaiser Permanente and the CDC. And they distributed 13,494 surveys between August of 1995 and March of 1996. And the questions on the survey looked at questions regarding abuse and household dysfunction, in general. Now these questions on abuse-- psychological, physical, and sexual in the household, dysfunction, substance abuse, mental illness, criminal behavior, even divorce-- were all part of these questionnaires. And these questions eventually became something known as the ACEs that is in a lot of research ever afterwards. And the interesting thing was they also included medical histories from the clinical questionnaire. And what they discovered is that there was a dose dependent relationship between traumatic exposure and medical outcomes in adulthood. They found those with diabetes. They found this with ischemic heart disease. They found this with cancer. And looking at it another way-- when you compare those who had no ACEs to people who had four or more ACEs, there were higher odds of sexually transmitted disease, alcoholism, injection drug use, diabetes, emphysema. So it's talked to-- talked about or described as the biggest study no one has ever heard about. The other study I want to discuss is the Women, Co-occurring Disorders, and Violence Study. So this study evaluated trauma-informed programs for women with a history of violence and trauma, with substance abuse and mental health disorders. So the importance of this study is what it did was start to really define what a trauma-informed intervention is. It really started to define it and put some science behind it. So they looked at 27-- 2,729 women at nine sites across the continental United States. And it was a quasi-experimental intention to treat study. Let's talk about the sites. So in the control sites, there were usual care. So, basically, a woman-- history of trauma, abuse, substance abuse-- comes in, gets evaluated, and basically is referred forward. So there's not trauma-informed staff. Services are not integrated. They just basically come in and get referred out. In the intervention sites, they had very comprehensive services-- crisis intervention, counseling, or parent skills training, resource coordination. The staff was educated on trauma and basically what that means to the patient. The services were integrated. So they had integrated mental health, integrated addiction services, integrated behavioral health. In addition, they had staff who were peer survivors that served as advisory roles and service provision roles. So what were some of the outcomes? So the outcomes were the Global Severity Index, which looks at basically distress, [INAUDIBLE] of distress, stressors. The PSS is the post-traumatic symptoms scale which looks at symptoms of PTSD. The Addiction Severity Index, looking at active alcohol use, and Addiction Severity Index for Drugs, which looks at active drug use. And these were the ranges. The higher the number, the worse the severity, in general. So looking at the numbers at baseline. So at baseline, there wasn't much difference between the intervention group and the baseline group, the comparison group who had usual care. After six months, there was-- ah, I went too fast. But after six months, there was a decrease in the GSI, the PSS score, the ASI score, the SID score in both the comparison and the intervention group. But in the intervention group, there was greater decreases. And in 12 months, the intervention group had statistically significant differences in the GSI Index and the PSS score. They didn't find a statistically significant difference in the ASIA or the ASID score. But what this led to was a-- the start-- the start to maybe these interventions, these trauma-informed interventions. Maybe there's something to this. Harris and Fallot wrote several-- several articles on trauma-informed care, and what that looks like, and what that's defined of. They looked at it from the standpoint of the personal provider and they looked at the standpoint from the system. So we'll-- these slides, this is kind of summarized for you. So in terms of the personal-- the provider themselves, what they suggest is know the history of the past and current abuse in the life of the patients, which is basically know your patient, right? That's just kind of being a good doctor. You should know your patient. Know their social history. Then understand the role of violence and victimization and how that plays in the life of the patient and deliver services that encourage participation in treatment. So this is getting at the idea of avoiding re-traumatization and trying to deliver services in a trauma-informed way. And then return a sense of control and autonomy to the survivor. So let me give you an example of this. Let's say you have a patient who has a cardiac condition. You want to do a cardiac exam. You want to get your stethoscope, listen to the heart. So one trauma-informed way to do this is you really speak out and describe every step of what you're going to do. You show them the stethoscope. Maybe even tap on it. Listen, I'm going to do a heart exam because I'm concerned about something going on in your heart. Then you show them what you're going to do before you actually touch them, all right? This is an abuse victim. So you show them what you're going to do before you actually touch them. And then you ask for permission. And I-- do you mind if I just put this under your shirt and listen to your heart? That's giving them a sense of control. Then let's say they say, no. Yes. Yes. I do mind. I don't want you to do it. So you give them autonomy. OK. We won't do it. We'll-- we'll try to find something else. Or is it OK maybe if I could put this over your shirt? I know it's not the greatest exam. But this is an example of how you give the patient autonomy. Then they had some recommendations for the system at large. One was administrator commitment to change. So that administrators, leaders, have to be committed to a trauma-informed paradigm. Second was universal screening. So this is screening everybody, especially if you have a location with a high prevalence. Screening everybody for depression, for anxiety, for substance abuse, screening everything, everybody, and just making that part of what you do. Training and education. Training every single person who has contact with the patient. If the janitor has contact with patients, you train them, all the way up to the physicians. Training everybody. Four was hiring practices. Hiring people who understand, who are willing to take in the trauma-informed paradigm. So being cognizant of who you're hiring, and reviewing policies and procedures. So reviewing the policies and procedures with a trauma-informed paradigm, are we promoting re-traumatizations with our policies. So just kind of taking a look into that and making changes related to that. This is a diagram from a paper by Leigh Kimberg in her chapter on trauma-informed care. And they really-- she describes what it would look like at the clinic level. What would a trauma-informed care clinic look like? So first, it starts with a foundation with trauma-informed values, partnerships, clinical championships-- champions, and looking and doing education on trauma-informed-- value and trauma-informed care at regular intervals. So providing that foundation. Second, the environment, providing a safe, calm, empowering environment for patients and staff so that every patient who comes in, all the staff members who participate know that this is a safe place. Safety is very, very big in trauma-informed care, have to feel safe. Then screening, inquiring about current and lifelong abuse, PTSD, depression, and substance abuse-- once again the universal screening that we talked about. And then a response. So onsite and community-based programs that promote [INAUDIBLE]. So having a way to refer, to respond, to their needs, particularly for patients who screened positive. And if you do not have that at your institution, then work on building community partnerships that do. So, at this point, we're going to transition a little bit, and we're going to transition more to what my particular chapter focused on, which is Trauma-Informed Care Focus on African-American men. But to really talk about this, I think it's important that we talk about a broader population. And what I'm-- the population I'm talking about in general is men. Men in general. So the reason why is that, according to the research, according to the studies, men react differently to trauma. Men consume health care differently. And we should consider this in our interventions. So one thing I want to say is that you cannot generalize all of these particular attributes to a particular man. Every man is different. So keep that in mind. But, as per the research, these are some of the findings from the sociological research and clinical research. One, that men are less likely to seek help for depression, substance abuse, physical disability, and particularly in the context of stressful lifes events. They're less likely to seek help. TWo, when seeking medical help, tend to ask less questions. Now this is modified by severity. Obviously, if you think you're dying, you're going to have some questions. But tend to seek-- ask less questions. Three, underutilize help available to them. And this is all going under the theory of the masculine gender role norms that are incongruent with professional help seeking. Let me give you an example. I don't know if you guys know who this man is, number 23. I'm not too sure if you ever heard of him. His name is Michael Jordan. So in 1997, there was a big playoff game. The Chicago Bulls versus-- I believe it was the Utah Jazz. It was 2-2. Michael Jordan came down with 101 fever in game five of this series and I'm sure that if you, as a physician, were to see anybody in your office with 101 fever and you're thinking that they credibly had the flu, you might make the recommendation that it's not a good idea to play a full court basketball game. Possibly. I don't know. Maybe that's just conjecture. Michael Jordan not only played this game. He scored 33 points, seven rebounds. It was fabulous. And the Chicago Bulls, obviously, won. And he was applauded for this. I mean, he was celebrated for this. I celebrated him for this. I thought it was one of the greatest playoff games ever, and the man was exhausted. You saw him lying on the shoulder of Scottie Pippen, his number two, in that game. But I would argue that if Michael Jordan would-- were to sit out that particular game, I don't think people would have taken that too lightly. That's my argument. So that's basically what I mean by gendered roles incongruent with professional help seeking. So here's another study. This is a study done by the CDC in 2012. So if you look at this graph, you might notice that when we're looking at physician office rates, in every single age group, men tend to have a lower rate than women in terms of outpatient physician office rates, with the exception of AIDS under 18. Now the reason is because, when you're under 18, you're a child and your parents make you go. But otherwise, this would suggest differences in behavior. So what I want to say is that when it comes to black men, everything I just talked about applies. Every single thing I just talked about applies. But there's some additional things to particularly consider. Now this is a-- this comes from the Web-based Injury Statistics Query and Reporting System at the CDC. It's called WISQARS. And anybody-- I used this because anybody could look this up for themselves, put in the same data that I put in, and get the same results. I looked at 2014 to 2015. So let's go-- let's go through this bit by bit. Gender, I put both, which includes women and it's stratified by race. Now "violence" refers to nonfatal injury related to assault, legal intervention, and self-harm. So those are the violence numbers. Injuries mean all violence related to injuries and accidents. So this is car accidents, falls, you know, looking at yourself in a selfie stick and falling down, anything. All right? All, all injuries. And then this is the population as per the CDC, your Census Bureau. And what we see is that proportion is the rates of violence per injury. And, in this particular table, we notice that black males have a higher proportion of non-fatal injuries. Now let's look at fatal injuries. We discussed what gender and race means. AADR is the adjusted death rate. Violence is the number of deaths related to violence. Deaths are the number of deaths related to all intents. All intents include suicides, and accidents, and things of that nature. And then there's homicide percent. So this is the portion of violent deaths that are homicide. And H over V is the proportion of homicides that are violent, related to violence. And, once again, African-American males have higher rates related in comparison to both. So this is a population that's exposed to a lot of trauma. Now this does apply to all black men in America. There are black men that don't really experience any of this stuff. But there-- there is a subset that do. Now some of the theories that's been discussed have been looking at some ecological exposes. So there's racism. There's neighborhood effects and poverty. We're going to focus on this, too, because those are the studies that I have. I don't have a lot of studies on poverty. But that could be a whole additional talk in itself. So let's be a little bit clearer about some definitions when we're talking about racism. Institutional racism relates to the codes, laws, and practices that disadvantage a particular race versus another. Personal mediated are the ones that we're more familiar with. It is kind of an individual person to person act against another person because of their race. And intrinsic. Intrinsic is a particular person who looks negatively towards themselves because of their race. And then we'll talk about some studies about neighborhood effects and how that affects men in general. So there is a paper by a woman by the name of Wizdom Powell. And this particular paper, she tried to look specifically at health-- health-- help. Health help-seeking, looking specifically at African-American men. And she used several theories for her study. So there is the Reactance Theory. Individuals are more likely to resist help when they confront life events that diminish their sense of control or threaten freedom. Race centrality, the importance of race to one's identity. Masculinity norms, which is described as emotional stoicism, toughness, and autonomous coping strategies. And John Henryism, that individuals can overcome demands with persistence and hard work. For those who don't know who John Henry is, this is a figure in the 1800s, an African-American man that did a man versus machine contest. And in this contest, he raced the machine to put in stakes into the railroad. Now John Henry actually won this match. But when he put down the last stake, he dropped dead. So the man literally work himself to death-- to death. But he won. So Dr. Powell had a hypothesis. And her hypothesis was that high degree of masculinity norms salience. And race-related stress events lead to decreased health seeking. And what she did is she had this incredible amount of measures. I'm not going to read all of them here. But there-- I just put all of them in there so you know that's a-- it's a lot. She looked at an incredible amount of measures. And I wanted to summarize the findings here. So what she found is that if there was an increase in masculinity norms, these were-- these patients were less likely to seek help with statistical significance. So it's less than 0.005. If they had a perceived increased in everyday racism-- this includes micro aggressions-- they were less likely to seek help. If they had an increased sense of control, increased sense of control, increased pride in self, they were more likely to seek help. And if they had an increase in depression, they were less likely to seek help. She also looked at John Henry-ism and she did not find a statistically significant association between that and depression, or help seeking. And in her conclusion, she stated that African-American male diminished health seeking is an attempt to restore autonomy, freedom, and sense of control in the midst of social identity threats. So then there were some studies looking at neighborhood effects. I'm not going to go into detail in all the neighborhood studies, but I'm going to just highlight a few. The hypothesis, in general, is less. Optimal exposes increased risk for health. And some of the-- there are a lot of theories. But one of the major theories is the phenomenological variant of ecological system theory that says poor health decisions are coping response to ecological stressors, strains, and conditions. So just to go through some of these studies briefly, in a study by Smith in 2005, focusing on African-American males, they found that neighborhood violence disrupts social networks and associated with self-reported post-traumatic stress. The study by Chang in 2005, they noticed that low SES neighborhoods are independently associated with increased peer and adolescent use. And a study in 1993, they noticed higher neighborhood unemployment associated with the increase in teenage pregnancy among adolescent males. Among adolescent males. So focused-- all of these are focused really on men. Black men in particular. So there are few studies that I found hopeful. And I want to highlight here 'cause I want to wonder, what might work? What's something we can do? And one study I want to talk about is called the BARBER-1 study. So the BARBER-1 study is a randomized controlled trial of a health-based promotion program that really focused on using the barber as a community advocate, in a sense. So, you know, the barber shop is common. I go to my barber. We have a good relationship. We talk. We chat it up. They're our peers. They're like, you know, around the same age. They're in the community. We all know them. And they're trusted. All right? There's a lot of talk that goes on in the barber shop, actually. So their hypothesis were socialization and cultural institutions can promote health. And basically they had a control group. The control group was going into the barber shop, giving them a pamphlet on hypertension, and saying, you know, why don't you hand out this literature and just, you know, try to promote going to your doctor and getting their blood pressure checked. The second was the intervention group. The intervention group actually trained the barbers to give personalized sex-specific peer messages. Some of the barbers actually measured blood pressure in the barber shop and did repeated messages within the barber shop, and really normalized speaking about blood pressure within the barber shop. And the results were pretty impressive. Looking at the intervention barber shops versus the control barber shops, they found the absolute group difference of 8.8% between the intervention barber shops and the control barber shops. And they actually motivated 50% of their patients to go see the doctor and get their blood pressure checked, which I think was pretty-- pretty impressive. Then there-- this is more related to trauma. These are hospital-based intervention programs. Right now we're going to talk about a paper that was actually a study done around here-- University of Maryland-- in trauma. So, basically, they looked at acutely hospitalized patients. And this-- this was a trauma population, and it was a really, really focused population. This was a trauma population of African-American males. And these particular African-American males were involved in the justice system. So it was an incredibly focused population. So they did a brief hospital intervention once they come in. So there's a case worker that comes to your room almost immediately after your incident. And then they link you up with long-term psycho-social-- long-term case management, including psychosocial needs assessment, mentorship, case management, and navigation. And just for time purposes, we'll go right into the results. So the results were reduced hospital re-admissions, reduced arrests and convictions, reduced employment. And, if you look at the before the program, looking at jail time, hospitalizations, and employment, there's some difference between the intervention group and the control group. But if you look at the control group after the program, the control group got referred out, but didn't get the intensive services. There's a drop in all of these particular outcomes. But the intervention group was actually much, much less. Impressively, much, much less. So this was an intervention that showed not only reduces in hospital admissions, but also reductions in societal issues-- employment, incarceration. So these were-- this is a hospital-based intervention program. And what's the next step from trauma-informed care? Some are going into something called Healing Centered Engagement. So we'll go through that quickly. Healing Center Engagement focuses on four things. One, that individuals and communities are agents of their own restoration. Like, one way communities shield themselves is to get involved in community activism, for example. One way where rich communities empower themselves. Incorporating culture and sense of an identity. Helping people understand that they're not the only ones who've been through what they've been through, that we can heal collectively, and just kind of bringing that to light. Assets, focusing on assets. Knowing that this particular person might have gone through some things, but there are particular assets that have led them to be successful and capitalizing on those assets. And, finally-- this is also an interest of mine-- is wellness. Wellness for us, the provider. For us to take care of ourselves because dealing with patients with trauma is not particularly easy. So to care for ourselves, continuing education, retreats, sabbaticals, to really consider caring for ourselves because it's not a necessarily easy job. And that is my talk. Right before 1. [APPLAUSE]