Dr. Mike Flaningham is a physician at the Siletz Community Health Clinic in Siletz, Oregon.
I very much appreciate Dr. Stillerman's thoughtful response, as well as the work of her and her co-authors to advance PACEs awareness in the health care system (How cool is it that one of the authors is a PACEs Connection member?!?!). I furthermore appreciate the ongoing discussion here on the PACEs Connection forum, started by Craig McEwen's post on ACPM's recommendations, then spurred by Dr. Gordon's response. I hope to respectfully add to the conversation and apologize in advance for my lack of brevity. I'm largely writing this in hopes Dr. Stillerman reads it, as I both value her insight and (frankly) am lobbying here.
I actually want to steer away from the topic of to screen with the ACE Questionnaire or not. It's definitely an important issue, though I think tends to turn the debate into an all or none scenario that I feel distracts us from the main goal. I used to use the Questionnaire a lot, but don't use it now. I found that it served as a great conversation starter for PACEs, and I've now evolved into starting that conversation other ways. To be clear, I'm definitely all for the Questionnaire, but feel that the main point is that we need to be addressing PACEs with all patients, however it's done.
Here, I instead want to specifically focus on the topic of how to better get the medical community engaged in addressing PACEs. This is of personal interest to me, as I'm a general internist who has worked in primary care all of my 22-year career. Despite all these years in medicine (re: I'm old), I didn't become aware of ACEs until 4-5 years ago. As a shameful example of the problem we're up against, it was a patient of mine who brought the emerging PACEs science to my attention, and not the NEJM, JAMA, ABIM, USPSTF, or other leaders of medical education and policy. I'll give the AAP credit for having published a statement on ACES 10 or so years ago, but as an adult medicine doc, this didn't enter into my world. I'll add that four years ago, when I brought up ACEs to the Chief of Pediatrics for the very large medical group I worked for at the time, he admitted that he had not heard of ACEs.
The patient who first educated me caught my attention because her complicated health issues had significantly improved through her own doing, and not from anything I (traditional medicine) had offered her. Being very curious as to what her secret was, I took her advice and read "The Body Keeps the Score" (by Bessel van der Kolk) and watched Dr. Nadine Burke Harris' TED Talk. Armed with this new information and perspective, and my fascination with neuroscience's recent understanding of the pathophysiology of chronic stress, my clinical approach slowly started to change.
However, it wasn't until six months later, when I had the inspiration to start using the ACE Questionnaire, that things really shifted. I'll never forget the ensuing, deeply meaningful conversation with my first patient who took the Questionnaire (she had 9 ACEs), sparking the epiphany that almost every health issue we primary care clinicians encounter is rooted in early life adversity and the behaviors people cultivate to deal with these traumas and after affects. I soon mentioned my eye-opening clinical experiences to a colleague, who then started screening some of his patients, and he had the same revelation. Everything now made so much sense to us that we naively assumed once we brought this to the attention of our medical group administrators and physician partners, they'd all "get it", too. Unfortunately, we were way off base and, with rare exceptions, what we pitched didn't resonate with other docs.
Four years have passed and my obsession with PACEs burns as strong as ever. I have no doubt that the patients I serve have benefitted from my now trauma-informed clinical approach, and I'm much less burned out than I was five years ago. I realize that this "n of 1" isn't evidence-based enough to prompt the ACPM to quickly revise their recommendations, but I also know that I'm not alone among physicians and APCs who "get it", and that we need to be the Johnny Appleseeds who spread PACEs awareness. I'm guessing that Dr. Stillerman and her co-authors share my obsession and that this fueled their efforts on the ACPM paper. So, how do we get our enormous beast of a health care system aligned with us? Dr. Burke Harris created wonderful momentum in California, showing that it is possible to move the needle. But it took the governor of the 5th largest economy in the world to wield his power in order to put her in a position to make change.
ACPM's recommendations, while largely in favor of advancing PACEs, are disappointing because they were made playing within the confines and rules of our medical culture (I'm mainly referring to physicians here). This culture is dominated by a thirst for evidence-based medicine and is, like our society's culture, generally uncomfortable addressing emotional health. I appreciate how an evidence-based approach took modern medicine out of the era of leeches and snake oil, into one where therapeutics have largely been safe and effective, but it seems like our medical culture has now become shackled to a need to be evidence-based. Every review article/lecture is expected to cite evidence supporting treatments, insurance companies deny treatment coverage that isn't evidence-based, and some medical groups base physician compensation on value (evidence) based care. Then there's the whole discussion on how medical culture's obsession with double-blind placebo studies, along with a reliance on pharmacologic treatments and shortened appointment times, have taken the humanity out of our profession.
We burned-out, change-resistant docs generally won't consider altering our practice styles unless there is an A or B rated recommendation from the powers that be, such as the USPSTF. Furthermore, it's going to be a long, long while before sufficient interest develops, momentum builds, studies are funded, time for studies elapses, PACE-supporting studies get published, debates/discussions occur, policy gets put in place, and then individual clinician practices adapt before the rubber finally hits the road and meaningful change takes place. We shouldn't and can't wait this long. There is harm—tremendous harm—in doing nothing.
In the case of ACPM's paper, the favorable recommendations get deflated by numerous caveats that use the usual medical-speak, such as "Despite limitations in the heterogeneity and quality of the published systemic reviews...", and "...require further implementation research", and "Prerequisite health system development is required...", and "...must have protocols and systems in place which support...healing-centered care."
To the overworked physician or health care administrator perusing through the ACPM recommendations, I fear that they will be underwhelmed by how the recommendations are presented, then quickly jump to the conclusion that addressing PACEs requires way too much infrastructure implementation and isn't ready for prime time. Also, I suspect that discomfort addressing childhood trauma will be used as further rationalization by the reader to take a pass on learning more about PACEs, and instead seek the familiarity of "real medicine", such as how best to update diabetes management protocols, or if heart failure patients should be on an SGLT2 inhibitor.
While a multipronged approach is necessary, I think that a key strategic intervention to effectively encourage physician engagement in PACEs is to get the editors of major medical journals to understand the importance of them. One challenge here, as recently alluded to by Dr. Gordon in a different thread, is that if you're not a clinician practicing in the trenches, you're less likely to understand the powerful, healing moments that can happen in the exam room when PACEs are addressed. It feels like medical journals are more interested in what's happening in the research lab than the exam room. This barrier aside, if editors truly understood that ACEs are at the root of most health problems and that a paradigm shift is in order, they would then publish studies, recommendation statements, and editorials that legitimize PACEs to the medical community.
This is undoubtedly a tall task. I've failed thus far and have the declined Letters to the Editor to prove it. Recognizing that I'm a lowly, community primary care doc who doesn't have an administrative title or PhD next to my name, a big motivation for writing this rambling response is to encourage Dr. Stillerman and her co-authors, who have their foot in the door, to try to get even more attention from the editors they have access to. And if they do, that they hopefully would be moved to use stronger, more forceful language than was used in the ACPM paper. They could feel empowered by knowing they're speaking for people affected by trauma (all of us), and maybe even infuse some passion and emotion (humanity) into their statements. This issue is of unique, paramount importance and is not just a discussion on what the best colon cancer screening test is. We gotta turn it up a few notches to get the attention PACEs needs.
Thanks for reading, and I welcome other perspectives, insights, and ideas.
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