Consented, p.20
Consented, page 20
Do you treat digestion, movement, breathing, or headaches? Childhood trauma increases GI disorders, musculoskeletal issues, respiratory problems, and migraines.27 If not, is it important for your patient to eat, move, breathe, or get out of bed?
Do you work with pregnant people or newborns? PTSD complicates pregnancy and postpartum health.28 If not, do you prescribe things or perform procedures that might affect pregnancy? Are at least some of your patients ever pregnant?
Do you treat chronic conditions? Struggling with PTSD increases the risk of many chronic illnesses, poorer overall health, and more days spent in bed.29 Even if you don’t, do you want your patients to feel better?
Do you prescribe medications? PTSD makes patients more likely to skip or forget to take them.30 No? Then when did you quit medicine?
Do you want your patients to exercise? PTSD reduces the likelihood of physical activity.31 And if you don’t emphasize movement, do you care about how people move in the state of their soul?
Do you work with a marginalized community? Historical trauma wrecks health.32 If not, have you considered whether you might be in the wrong profession?
I should also mention that a traumatized patient is four times more likely to attempt suicide and has higher all-cause mortality.33 Does your department fall under “all causes”? Yes. Yes, it does.
So now that we’ve established trauma is everyone’s department, how often do we actually ask about it?
In facilities treating substance use disorders, 80% of patients have experienced at least one traumatic event in their lives,34 yet such facilities offer trauma counseling only about 67% of the time.35 Roughly 58% of pediatric patients and 81% of adolescents carry traumatic memories,36 yet pediatricians ask about ACEs only 68% of the time.37 In pediatric trauma centers, where 24% of patients experience acute distress and 26% develop PTSD within a month, mental health screening is provided less than half the time.38 Meanwhile, in adult trauma centers, where approximately 68% of patients eventually become depressed and 44% develop PTSD within a year, psychological trauma is routinely screened just 28% of the time.39 Primary care doctors provide care for patients represented across all of these statistics—meaning that more than 80% of adults and 58% of children they treat have experienced trauma.40 Yet they inquire about it only 27% to 44% of the time.41
These numbers are dizzying. But one thing remains steady: Trauma is not the exception. It’s the norm. And even if only 1% of our patients had suffered trauma, their lives would still be altered in significant ways. As clinicians, that makes asking about our patients’ trauma 100% our responsibility.
No Sides in Healing
There is one department in medicine where 100% of patients carry trauma, and 100% of clinicians know it: street medicine.
Instead of practicing medicine from behind sterile clinic walls, street medicine takes its practitioners under bridges and between highways, in alleyways and tent encampments. Street clinicians wear hiking boots and kneel beside patients who are unsheltered, unheard, and too often unseen. Currently, there are over six hundred thousand people experiencing homelessness,42 who are often hungry, sleep-deprived, cold, wet, and sick. They constantly fall victim to assault, rape, theft, and even murder,43 and they are dying at ten times the rate of the general population.44
My friend and mentor, Dr. Jim Withers, has been walking these streets for over three decades. In 1992, he founded the first formal street medicine program in Pittsburgh. Since then, the movement has grown to an estimated 150 programs across the United States and spread to over 140 cities in twenty-seven countries.45 If anyone understands how trauma shapes health, it’s street docs like Jim. But not everyone sees him the way I do.
“One resident was clearly skeptical about me,” Jim said during our Zoom call. He’s wiry and soft-spoken, with an ever-present twinkle in his eye when he talks about patients. “We were visiting Neil, a Black patient with severe kidney disease, who was drinking himself into the ground every day.”
Neil was on the verge of being evicted from his temporary housing because his place was always covered in trash. When Jim and the resident walked into his room, they found Neil passed out on a soiled mattress, with urine and vomit on the floor.
“The resident looked disgusted. He pressed himself against the wall as if there was fault line in the room and he didn’t want to risk ending up on Neil’s side.” Jim walked over, stepping over empty bottles and discarded food wrappers. “He was so drunk I wasn’t sure he saw us come in,” Jim recalled. “Then suddenly, he whipped around and pointed at the resident: ‘Why you looking at me like that?!’”
The resident froze. “I’m gonna get you!” Neil shouted, raising his fists in the air before immediately dropping them, the weight of his own arms too much for his ninety-eight-pound frame.
For the next fifteen minutes, Neil vented about his neighbors, who stared at him with the same contempt. Jim sat beside him on the mattress, steadying Neil with one hand so he could meet his gaze while he listened. After Neil was done, Jim knelt, swapped Neil’s wet socks for dry ones he always carried in his doctor’s bag, checked his vitals, and confirmed he was medically stable. Then he called his social work team to see if the housing authority could give Neil a second chance.
“Hey, doc!” Neil slurred, his voice softening, “Love you, man!”
The resident didn’t say a word until they got back to the car. There, he asked: “What’s wrong with that guy?”
I know that question well. I’ve asked it myself about many patients. Why won’t this patient follow the plan? Why don’t they just take their meds? Why didn’t they follow up with me? Why won’t they help me help them? What’s wrong with them? But here is what’s really wrong: the questions themselves. When we ignore trauma, we ask the wrong question.
Neil wasn’t a man who simply refused to quit drinking. He was a man born into poverty to parents who were both alcoholics. Then he became a young man who lost his job after a DUI, lost his home because he didn’t have a car to take him to work, and lost his safety after ending up on the streets. He was beaten, assaulted, looked at with contempt, viewed as a problem, and treated as less than. Each time he tried to get help, things improved just enough for others to walk away. Then the next fall came. Nothing was innately “wrong” with him. But a lot happened to him and kept happening to him. Turns out, trauma is the through line for nearly everyone experiencing homelessness, most of whom battle mental illness and addiction.46 And trauma makes addiction more likely, more intense, and more punishing.47 The cycle continues.
As clinicians, how we treat people matters more than how we treat diseases. While diseases don’t remember the past, people do—and often for a lifetime. When we isolate a patient in a vacuum of time and ask why they refuse to move forward despite our nudging, we ignore the forces that have long been pulling them back into the darkness. It’s only when we are willing to see the full picture that we can shift from frustrated questioners to informed co-discoverers of truth, from exhausted reminders to energized partners in health, and from burnt-out healthcare providers to the healers we set out to be.
That’s trauma-informed care (TIC), a healthcare approach that begins with the whole story. It operates with the understanding that trauma is widespread and its impact far-reaching; the awareness that even healthcare professionals with the best intentions can retraumatize patients; the recognition that the ways trauma presents physically and emotionally may not make sense until we see the whole person; and, finally, the active integration of this knowledge into policies, procedures, and practice.48
“We practice trauma-informed care on steroids, man,” Jim told me. “Step one? Don’t be an asshole.”
While “assholeness” isn’t a clinical metric (yet), the introduction of TIC in 2001 has given us measurable proof of this philosophy.49 A 2024 systemic review found that TIC makes practitioners more empathetic and trustworthy, and less likely to retraumatize patients. It also leads to more flexible healthcare delivery, increased support from social agencies, and greater promotion of culturally aligned care.50 In short, TIC helps us be less of an asshole, which helps patients trust us more.
And the benefits don’t stop there. On the patient side, TIC has been shown to reduce anxiety and depression, enhance mental and physical health, lower hospitalization rates, encourage engagement with healthcare services, reduce ER utilization, and empower patients to take ownership of their care.51 On the clinician side, it decreases burnout, lowers staff turnover, supports professional growth, and helps institutions move toward meaningful, lasting improvement.52 In other words, TIC gives us the job we always wanted—you know, the one where we actually help people.
But really, when we become trauma-informed, there is no longer a patient side and a clinician side. There is only the same side.
Play Some Music
After Jim told me about Neil, something stuck with me for a long time. Even half-conscious, Neil felt the resident’s cold gaze cutting through him like it had many times before throughout his life. He saw the same look in the friends and family who gave up on him, the cops who shoved him, and the passersby who stepped around his body like it was trash. No drink was strong enough to dull the sting of the resident’s look, shattering him once more.
Without TIC, what we do in medicine can indeed retraumatize people. Like Jim, I also work with a community steeped in trauma. My patients, primarily Latine and immigrant, have endured unimaginable pain. One of the most common remnants of that suffering is the way their pain has been dismissed by people in healthcare.
“Ay ay ay, me duele, me duele!” my sixty-two-year-old Spanish-speaking patient, María, squirmed on the table. It hurts, it hurts! I was removing a skin cancer from María’s leg. After a lifetime of hard labor under the scorching sun, this wasn’t her first skin cancer removal.
“Really?” I asked, skeptical. The skin had turned pale where I had injected the numbing medicine, a sign that it had taken effect. I have always been generous with my numbing medicine, and I always wait for at least fifteen minutes before starting my procedures. I even play relaxing music while I wait! It should have worked.
“Do you want me to give you more medicine?” I checked my watch. We were already thirty minutes into an hour-long procedure. In my peripheral vision, I saw her bypass my gaze and nod at Sydney.
“Yes, please!” Sydney answered, making a request on the patient’s behalf.
I turned to see Sydney holding the patient’s hand. In the sterile procedure room, the divide of our patient’s trust was clear. Sydney and the patient stood together on one side, and I stood on the other. That was when I knew I had screwed up. I mustered a warm smile, which probably looked more like a guilty grin, and walked to the medicine cabinet to draw up more anesthetic.
“Thank you for holding her hand,” I whispered to Sydney, who, with her quiet solidarity, had once again shown me the right way to be with our patients. “Would you mind staying behind to talk with her after I give her more medicine?” Sydney nodded and gave the patient’s hand a reassuring squeeze.
Later, I found Sydney and asked, “I’m missing something, aren’t I?”
I sure was. During the time we waited for the additional medicine to kick in, Sydney found out that eight years ago, another doctor had removed a skin cancer for María in Mexico. He had done such a poor job with pain control that she felt everything. When she begged him to stop, he refused. She never visited another doctor again until her daughter urged her to get a spot on her leg checked out.
It’s better to assume everyone has lived through trauma, my professor’s words echoed in my mind. Shame and regret flooded me. The truth was, beyond a brief mention in a physical exam practicum, TIC was never explicitly taught to me. And I was hardly alone. In 2017, only 27% of US family medicine residency programs reported having TIC training, with most offering less than five hours a year.53 A 2025 survey found that only 20% of American and Canadian OB-GYN programs offer annual TIC education, with over a quarter offering none at all.54 While data on emergency medicine remains outdated, a 2013 study found that over 70% of programs either lacked specific SAFE exam requirements or only required future physicians to observe one such exam before graduation.55 More alarmingly, although the American Psychological Association (APA) approved trauma-focused competencies in 2015 as part of its education and training policy,56 by 2023, only 5% of APA-accredited psychology programs required a course in TIC. The result? Just 8% of newly minted doctoral-level clinical psychologists entered the field with formal TIC training.57
Without TIC, we fail even to ask about trauma, let alone recognize it.58 How do we begin to avoid retraumatizing patients?
“Do you think . . . maybe . . . she will let me try again?” I asked Sydney cautiously.
Sydney giggled at my guilty look and answered: “I think so, doctora!”
We returned to the room. This time, instead of reaching for gloves first, I placed a gentle hand on María’s arm and met her gaze. I told her I was sorry for what she had endured in the past. I asked if she wanted to tell me what that other doctor had done wrong, so I wouldn’t repeat his mistakes.
“He said I wasn’t actually feeling pain.” She looked to Sydney, who smirked.
“Let me guess . . . ” I said sarcastically. The patient looked bemused.
“Just pressure,” Sydney finished.
We all laughed at the ridiculousness of those dismissive words. The room shifted. I promised to do everything I could to keep her comfortable. “And if you tell me you hurt, say, by frowning or saying ‘ouch,’ I will stop. I will numb you more. No questions asked. Okay?”
María looked at Sydney, who nodded to signal I was to be trusted. “Okay.”
After double-checking the numbing effect with a small needle, I began the procedure. I asked Sydney to sit beside María and keep holding her hand, and if her grip tightened, to let me know. And when she did, I stopped and asked if she was in pain. Before I used electricity to cauterize the bleeding vessels, I demonstrated the sound it would make and warned her about the smell. Before flushing the wound, I told her she might feel liquid dripping, but it wasn’t blood, just saline. I moved quietly, careful not to make clanking sounds with the metal instruments and startle her.
We talked about her kids and grandkids. We shared favorite foods. We laughed about how my dad insists on using the dishwasher as a drying rack, and she told me how stubborn her husband was in return. Then she gave me advice on managing family dynamics.
“The secret is to make them think they came up with the ideas to behave better themselves!” Sydney giggled as she interpreted for María.
Like how you are making me think I came to my senses and avoided retraumatizing our patient on my own? I asked telepathically.
Exactly, Sydney winked.
“Sorry for overreacting,” María said after the surgery.
“You didn’t,” I told her. “It’s totally normal to feel anxious, especially considering what happened before. Is there anything we could do next time to make it less scary for you?”
“Yes,” she said, surprising both Sydney and me. “Next time, try playing some Mexican dancing music!”
TIC is more than just playing relaxing music. We need ongoing, high-quality, evidence-based TIC curricula in schools59 and training in the workplace. Fortunately, efforts to incorporate trauma-informed care into health professional training curricula are currently underway across all healthcare professions.60 In the meantime, we must continue to teach ourselves trauma-informed practices, and remain grateful to our patients who give us second chances.
Because a future where we stop retraumatizing people and start fully honoring their whole existence? That’s something we can all dance to.
First, Do No Harm
I stood outside the radiology department, clutching an empty catheter bag. Maybe standing isn’t the right word. I shifted my weight from foot to foot—sort of hopping—trying to ease the pain between my legs and inside my belly. I was told to hold my urine, or rather, what they had just pumped into my bladder through a catheter. I was told to hold my tears. But I couldn’t do both. So I let the tears run freely.
I was ten and had appendicitis. In 1998 Beijing, the protocol for visualizing a child’s appendix via ultrasound often required filling the bladder with saline to allow a clearer view.61 The result was often a feverish child—restrained, catheterized, and forced to endure an excruciating bladder fullness. I sobbed outside the ultrasound room, rocking left and right, right and left. My mother stood beside me and stretched out her hand, offering to hold the catheter bag for me. But just minutes earlier, she had let adults pin me down, pry open my legs and shove a stiff tube into me. I slapped her hand away.
Then a fresh wave of sharp, nauseating pain hit. I doubled over, retching into a trash can, only to be snapped upright by the searing poke of the catheter in my bladder. Yellow bile splattered onto my arms and shirt. I wasn’t sure what hurt more: my ruptured appendix, my forced-open urethra, the humiliation of standing in my own vomit, or the realization that adults in medicine could be so cruel.
The morning after my appendix was removed, the surgeon came to check on me. He was a kind-looking man with warm hands. But when he tried to pinch my cheek in a gesture of endearment, like adults often did to kids in China, I jerked away.
“Don’t be rude!” my mother scolded. “Say thank you!”
“Thank you,” I whispered, my face turned toward the wall.
Until now, I have never spoken of this memory. Maybe memory isn’t even the right word, because for two and a half decades, it was buried in an unretrievable corner of my mind—until I saw the drawing. In it, a stick figure child lay on a table, legs spread open. A terrifying adult woman stood over her, shoving something that looked more like a sword than a medical instrument between them. Three boys with grinning faces circled her, cameras in hand. The child screamed, “No! No! No! No! No! No! No!” The pencil drawing was black and white, except for one thing: a single drop of red blood between the child’s legs. Beneath the image, in jagged, uneven letters, the young artist had written: WHAT A VCUg FelT like TO Me.
