Excellent Harvard Health Blog Post

Sometimes people wonder whether it is better to seek traumas by specific questions while others feel they should search for plausible trauma outcomes and then work backwards.  As a result of our ACE Study findings, we decided to integrate specific ACE questions into our very lengthy general medical history questionnaire that was Step 1 of a system of unusually comprehensive adult medical evaluation that we had at Kaiser Permanente in San Diego.  This was used with 440,000 middle-class adults over a multi-year period.  Importantly, the questionnaire was filled out at home, not in the waiting room.  Yes answers were dealt with in the exam room by saying to patients, "I see on the questionnaire that .....  Can you tell me how that has affected you later in your life?"  And we listened, period.  And as a result of unsought patient feedback, we slowly realized we were doing one other thing: We implicitly accepted people who had just shared the dark secrets of their lives.  A note from an elderly woman typified this feedback: "Thank you for asking.  I feared I would die and no one would ever know what had happened.  And they were still nice to me."  Word of this kind of feedback led a University of California mathematician with a start-up data mining company to do a 135,000 patient study to see whether the addition of these ACE questions had any detectable outcome.  It turns out that they triggered a 35% reduction in outpatient visits and an 11% reduction in ER visits in their subsequent year compared to their prior year.  

Although we had no patient complaints, there were multiple colleague complaints:  "What the hell am I supposed to do with this?  This was 50 years ago."  or "If I wanted to be a shrink, I'd have been a shrink!  I'm a cardiologist."  

It looks like the relevance of ACEs is catching on, from schools to 21 State Legislatures that have seen the advantage to their MedicAid budgets of a 35% reduction in doctor office visits  (see California Assembly Bill 340).  It's even starting to catch on in some medical practices!

Excellent overview of the logic and premises behind trauma informed care written by a practicing general internist, Dr. Monique Tello.