The effect of patient evaluations for ACEs on doctor visits
From a webinar by the Academy on Violence and Abuse
Dr Vincent Felitti, one of the authors of the original Adverse Childhood Experiences (ACEs) study, featured recently on a webinar about ACEs. During that session, he spoke about what happened when doctors in general practice understood the ACEs that their patients had suffered:
If we're going to improve the future and go from child health and wellbeing, where it stands today, to adult health and wellbeing where it might be, two things are going to be involved. One, is understanding that these problems commonly occur and two, routinely seeking ACE histories in medical practice.
We've had some significant experience with integrating the ACE study findings into medical practice. We introduced ACE questions into our 10 page medical history questionnaire that everyone had to fill out as step one of comprehensive medical evaluation. That has had a profound effect on doctor practices (GP surgeries) in the following year.
We integrated trauma oriented questions that many colleagues assured us they would not be answered, they were wrong. It turns out that there was no patient resistance in a 440,000 adult patient sample, where we did this over a number of years and they're routinely asking everyone. The way one inquires also matters a great deal. Starting with a well devised,10 page medical history questionnaire is far more productive than starting face-to-face with these questions.
The routine use of these questions has markedly transformed our ability to understand and treat many problems that previously seemed intractable as well as confusing. We collected this 10 page history at visit one, pass it into a digital scanner that picks up all of the yes answers and gives us a nice organised laser printout, organised by body systems.
We have this information in hand routinely before even meeting the patient. And then in the examination room, the way we used it, was, "I see on the questionnaire that... Can you tell me how that's affected you?". And we listened. Period. We did one other thing too. We implicitly accepted that person. A very important idea.
How does that play out? When we have worked using a purely biomedical evaluation without the ACE questions, going through comprehensive medical evaluation as we carried out, led to an 11% reduction in a doctor office visits in the subsequent year. We felt that that was really the result of a more comprehensive diagnosis, more organised entry into a complicated medical care system, etc.
When we integrated the ACE questions, in a 135,000 patient adult sample, integrating the ACE core questions led to a 35% reduction in doctor office visits and an 11% reduction in A&E visits. That has a multi-billion dollar implications for the cost of medical care.
This has led to 23 state legislatures in the United States passing legislation designed to support the routine collection of ACE information in medical practice.
So as you can see, asking and listening and implicitly accepting is a powerful form of doing. Routinely I am stopped in the office in the hallway by patients leaving at the end of the second visit who tell me that they want to thank me for asking those questions and then often tell me how grateful they are to the doctor who after hearing the dark stories of their life, was still nice to them. He/She wants to see me again. Asking and listening and implicitly accepting are a very powerful form of doing.
We can summarise what we've been talking about this way. That we start with a very large base of people with adverse childhood experiences, which are overwhelmingly unrecognised. We know now that those disrupt brain development, producing social, emotional, and learning impairments, and we know that by the time those individuals become teenagers, they have enough freedom to try to find something that helps and tobacco helps, sex helps, nicotine helps, alcohol helps, eating helps. Those things that help in the short term produce major problems. Long-term disease, disability, social problems, and a number of people die early. Insights from the ACE study might be summarised this way. That adverse childhood experiences are common and an overwhelmingly unrecognised. Their link to major problems later in life is strong, proportionate and makes sense. They are the nation's most basic public health problem.
And it's comforting to mistake intermediary mechanism for basic cause. Now McDonald's is why that kid's fat. We don't look any further than that. What presents as the problem may in fact be somebody attempt at solution, and unwittingly attempting to take their solution away may be threatening and hence cause flight from treatment or failure. And that primary prevention, figuring out how to stop this from happening in the first place is the only feasible population approach. And this might be done by improving parenting skills across the nation. We don't know how to do that yet, but it's a very important potential to consider and to think about seriously.
So we saw that a bio-psychosocial childhood trauma oriented approach to adult medical evaluation has been feasible, affordable, and very acceptable to patients, though not necessarily to my doctor colleagues. That it's possible to move from our current symptom reactive mode of practice and start dealing with underlying causes and thereby significantly improve medical care while improving and reducing its cost.
Watch the full 90 minute webinar here (the above comments are from 50 minutes onward)
Churches are ideally placed in their community to raise awareness about ACEs with parents, educators, etc. Why not arrange to facilitate the Resilience Challenge?
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From a webinar by the Academy on Violence and Abus, 09/06/2021