The secret to better care: It really is all in your head

For nearly 15 years we've had the secret to delivering better care at lower cost in America.  The information has sat, hidden away in the medical literature, and barely mentioned among physicians.  It's a remarkable story of bias. The neglect of this information by the medical community tells you a lot about our failings as a profession and the poor training we receive.  It's also a powerful commentary on the values of our society and the biases built into our society's view of health and healthcare.

In the 1990's, a physician at Kaiser Permanente in California, Dr. Vincent Felitti, conducted a mail survey with 17,000 middle class patients.  He asked them questions about traumatic events that might have happened to them as children.  Incredibly, over 70% of people receiving the survey responded, and they gave permission to connect their survey answers to their medical records.

The survey asked questions about things like death of parent, physical abuse, sexual abuse, and substance abuse by a parent.  Nearly 50% had at least one of the Adverse Childhood Experiences (ACE), and he coined the term "ACE score" for the point score created for the survey.

Incredibly, the ACE score predicted healthcare utilization, healthcare spending, obesity, substance abuse, smoking, alcoholism, and prevalence of poorly controlled chronic disease better than anything we've ever found.  In short, the terrible things that sometimes happen to children can cause a lifetime of health impacts.  This is true even for middle class patients.  However, poverty magnifies the potential to have a higher ACE score and probably exacerbates any traumas that have occurred.  You can read the report of his study by clicking here.

In the years since the study was published, our understanding of the brain has caught up with these findings.  Science is beginning to explain the toxic impact of early life trauma on the developing brain of a child.  It causes re-wiring with physiological and anatomical changes that become maladaptive in later life.

In the work that I do in the City of Camden building interventions for high-cost complex patients, the issue of early life trauma and compounding later life trauma has become a core one.  Many of our high utilizers of the local healthcare system tell us horrible stories of their childhood, when asked.  We've recently published research on these findings.  To read our report, click here.

In my training as a family physician, I was told not to pull up the lid on something you don't have the time and training to deal with, like early life trauma.  I am deeply embarrassed in looking back at my career caring for patients in Camden because I followed this advice too often.  It's likely that many of my patients had early life trauma that was probably sitting right below the surface, but I rarely asked.  It's frightening to open up a Pandora's box in a 10-15 minute visit of an overwhelmed primary care office.

Some physicians, like Dr. Nadine Burke, a pediatrician in California, are leading the way in bringing ACE scores into clinical practice.  Her work was described in an article in the New Yorker magazine, which you can read by clicking here.

I believe ACE scores should become a vital sign, as important as height, weight, and blood pressure.  There was a time when physicians were reluctant to ask about and address smoking, unsafe sexual activity, and obesity.  The taboos and discomfort about discussing childhood traumas with patients needs to be lifted as well.  Asking a patient about abuse in childhood will not cause them to become suicidal or emotionally unstable as some physicians think; it's a vital piece of information, more important than all of the other information we collect.

It's interesting to ask why this information hasn't permeated medical training, healthcare reform efforts, or even our broad cultural narratives about health and healthcare.  It's becoming clearer and clearer in the research literature that mental health, addiction, and early life trauma are extremely important drivers of health outcomes and health spending.  The answer is simple: our society has a huge cognitive bias against discussing these issues and the medical community is a reflection of such broader biases.

I believe we need more trauma victims to publicly discuss how their early life experiences have impacted their life and their health and we need more physicians to talk publicly about the importance of this issue.  We also need research on ways to bring ACE scores into routine primary care.  The stigma surrounding early life trauma needs to be lifted.

For more information about this topic, you can visit the Camden Coalition of Healthcare Providers website.

You can view a draft video we're working on to increase the visibility of this topic by clicking here.  If you have feedback, please feel free to share it with our team.

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