Writing in the October 10, 2018 New England Journal of Medicine, Eve Rittenberg, MD, assistant professor at Harvard Medical School and practicing physician at Brigham and Women’s Fish Center for Women’s Health, reflects on the impact the Kavanaugh hearing and #MeToo movement have had on patients who have experienced sexual violence. Important principles of trauma-informed care—including ways to ask permission, offer control, and find support—described in her article and in Monique Tello’s post below can make a real difference to many women and health care professionals alike.
Many years ago, when I was a trainee, I helped take care of patients at a family medicine clinic.* One day, a school-aged brother and sister came in for their annual physicals. They were due for vaccines. Neither wanted any shots, and they were both quite upset. “You’ll do what the doctor tells you, is that clear?” ordered the mother. She and the nurse worked together to hold the sister’s arm down. But just as the nurse was about to deliver the injection, the young girl jerked her arm away and ran to the opposite corner of the room, crying. The brother then ran over and stood in front of her, his arm outstretched, guarding, and yelled “Get away! Leave her alone!” At first, the focus was on forcing them to have their shots, which were required for school. But it only made things worse. The young girl screamed, the boy fought, no one could calm them, and everyone was annoyed.
One of the senior doctors finally conceded: Let them go, we’ll have to work on this. But that family never returned.
Months later, we learned that the children had been removed from the home by the Department of Children and Families, for parental abuse. I could only imagine what had been happening.
*This vignette is based on a composite of several cases I have been involved with over the years. All potentially identifying details have been changed to protect patient privacy.
The prevalence of trauma
The CDC statistics on abuse and violence in the United States are sobering. They report that one in four children experiences some sort of maltreatment (physical, sexual, or emotional abuse). One in four women has experienced domestic violence. In addition, one in five women and one in 71 men have experienced rape at some point in their lives — 12% of these women and 30% of these men were younger than 10 years old when they were raped. This means a very large number of people have experienced serious trauma at some point in their lives.
Medical exams by definition can feel invasive. They often involve asking sensitive questions, examining intimate body parts, and sometimes delivering uncomfortable — even painful — treatments. So, it is important that healthcare providers are mindful of the fact that so many people come to that healthcare interaction with a history of trauma.
Could the case I described have been handled differently?
There have been some recent news articles about a relatively new (and improved) way for health professionals to approach patients. This is called trauma-informed care. Dr L. Elizabeth Lincoln is a primary care physician at MGH who has trained medical professionals and students about approaching patient care with an understanding of trauma. She explains: “Trauma-informed care is defined as practices that promote a culture of safety, empowerment, and healing. A medical office or hospital can be a terrifying experience for someone who has experienced trauma, particularly for childhood sexual abuse survivors. The perceived power differential, being asked to remove clothing, and having invasive testing can remind someone of prior episodes of abuse. This can lead to anxiety about medical visits, flashbacks during the visit, or avoidance of medical care.”
What does trauma-informed care look like?
The first step is to recognize how common trauma is, and to understand that every patient may have experienced serious trauma. We don’t necessarily need to question people about their experiences; rather, we should just assume that they may have this history, and act accordingly.
This can mean many things: We should explain why we’re asking sensitive questions. I might say, “I need to ask you about your sexual history, so I know what tests you may need.” We should explain why we need to perform a physical exam, especially if it involves the breasts or genitals. If someone is nervous, we can let them bring a trusted friend or family member into the room with them. I’ve had many female patients hold someone’s hand during a pelvic exam. We can tell them that if they need us to stop at any time, they can say the word. If someone refuses outright to have a certain exam or test, or if they’re upset about something (like having vaccinations), we can respond with compassion and work with them, rather than attempting to force them or becoming annoyed.
For someone who has experienced trauma, the hospital or doctor’s office can be a scary place. Dr. Lincoln explains: “Patients often do not volunteer such information about prior experiences, because of guilt or shame. Medical professionals often ask about safety in a patient’s present relationships, but few ask about past experiences. A simple question such as, “Is there anything in your history that makes seeing a practitioner or having a physical examination difficult?” or, for those with a known history of sexual abuse, “Is there anything I can do to make your visit and exam easier?” can lead to more sensitive practices geared to developing a trusting relationship. Patients can advocate for themselves by explaining to physicians their anxiety about medical visits, why this is so, and what they have found helpful or harmful in prior healthcare encounters.”
Trauma comes in many forms
It is also important to note that there are many types of trauma. A colleague of mine has a child who survived a life-threatening illness. Prior to his ICU stay, he never flinched at vaccines; since his hospitalization, any needle sticks make him extremely anxious. Another colleague describes how after years of invasive infertility treatments, and despite becoming a mother, she sobbed uncontrollably at her simple routine gynecologic exam, because it touched such a nerve of helplessness and failure. Trauma-informed care is the open-mindedness and compassion that all patients deserve, because anyone can have a history that impacts their encounter with the medical system.
We as providers need to recognize that many, many patients have a history of physical, sexual, and/or emotional abuse, as well as serious illnesses and negative experiences in the medical setting, and we need to learn to respond with empathy and understanding.All too many women recognize the signals of a urinary tract infection, or UTI: pain and burning when urinating, coupled with a frequent urge to do so. A simple change in behavior could help prevent a common UTI known as recurrent cystitis in women, according to a randomized controlled study published in JAMA Internal Medicine in October 2018. The study showed that drinking more water daily led to fewer episodes of recurrent cystitis and less need for antibiotics.
What is cystitis and what causes UTIs?
Cystitis refers to an infection in the bladder, which most women know as a urinary tract infection. Cystitis is extremely common among women, partly because female anatomy increases the risk of infection due to the proximity of the urethra to the anus. Additional risk factors for cystitis include sexual intercourse, diaphragm use, spermicides and spermicide-coated condoms, and a prior history of cystitis. Women with diabetes and those who have abnormalities of the urinary tract are also at increased risk for cystitis.
The vast majority of infections (up to 95%) are caused by one bacteria, E. coli. Signs and symptoms of an infection include pain with urination, increased frequency of urination, and an increased urge to urinate.
What is the treatment?
Cystitis is treated with antibiotics for three to five days, depending on the antibiotic used.
Can UTIs be prevented?
If you’ve ever had cystitis, you may have heard suggestions that are mostly based on anecdotal evidence. To decrease risk for cystitis, women are advised to urinate after intercourse, drink cranberry juice, drink more fluids in general, and keep the perineal area that lies between the urethra and the anus clean. Evidence is mixed on whether these steps may help prevent cystitis. This study sought to provide direct evidence of the benefits of drinking extra fluids.
What did the study tell us?
The study participants were 140 premenopausal women who experienced three or more episodes of cystitis in one year and reported that they drank less than 1.5 liters of fluids daily, which is about 6 1/3 cups. The average amount participants drank daily was a bit over a liter (1.1 liters, or about 4 1/2 cups).
The women were randomized to one of two groups. Every day, one group drank their usual amount of fluids plus an additional 1.5 liters of water. The control group drank just their usual amount of fluids. The women kept journals recording the type and amount of fluids they drank in a day. Their urine was periodically measured for volume and tested for hydration status. The study discovered that women who drank an additional 1.5 liters of water had 50% fewer episodes of recurrent cystitis, and required fewer antibiotics than women who did not drink additional fluid.
Is it safe to drink this much fluid?
While the amount of extra fluids tested in the study may seem like a lot, the Institute of Medicine recommends that women have 2.2 liters daily, which is about 9 cups. Not all of this needs to come just from water — or even fluids. Fruits and vegetables, which are part of a healthy diet, contain a lot of water.
This study used a rigorous scientific method to evaluate the benefits and risks of an inexpensive and safe anecdotal treatment. While it has been suggested that substances in cranberry juice can decrease the risk of urinary tract infection, no studies have conclusively demonstrated its benefits. Water may be the best means to increase hydration because it is inexpensive and has no calories. Although this study focused on women who had recurrent cystitis, its results could be extrapolated for a lower-risk population as well.
If you’re a woman with symptoms of cystitis, such as pain or burning with urination, increased urgency and frequency, try to drink more fluids, but also call your health care team for evaluation. A simple urine test in conjunction with the symptoms you describe may provide enough information for your health care provider to confirm an infection and start you on a brief course of antibiotics.
Better still, going forward, you may be able to decrease the chance that you will develop an infection by drinking more water daily. It’s a simple solution readily available for prevention — and now supported by evidence!6 steps toward a successful exercise resolution
Many people have decided to try the ketogenic diet for weight loss. The most recent evidence shows that reducing your carbohydrate intake to a minimum may help you shed a few pounds, at least in the first few weeks to months. However, we don’t really know whether, over the long term, achieving and maintaining ketosis is better for weight loss than other diets. Almost any intervention can cause undesirable consequences, and the ketogenic diet is no different. One of the most well-publicized complications of ketosis is something called “keto flu.”
What is keto flu?
The so-called keto flu is a group of symptoms that may appear two to seven days after starting a ketogenic diet. Headache, foggy brain, fatigue, irritability, nausea, difficulty sleeping, and constipation are just some of the symptoms of this condition, which is not recognized by medicine. A search for this term yields not a single result on PubMed, the library of indexed medical research journals. On the other hand, an internet search will yield thousands of blogs and articles about keto flu.
It is tricky to describe exactly what happens after the diet change, because we are left with only our own observations and experiences. These symptoms may not even be unique to the ketogenic diet; some of my patients describe similar symptoms after they cut back on processed foods, or decide to follow an elimination or an anti-inflammatory diet.
What causes keto flu?
Well, we don’t really know why some people feel so bad after this dietary change. Is it related to a detox factor? Is it due to a carb withdrawal? Is there an immunologic reaction? Or is this a result of a change in the gut microbiome? Whatever the reason is, it appears the symptoms attributed to the keto flu may happen, not to everyone but to some people, after “cleaning up” their diet.
Many years ago, when I was a trainee, I helped take care of patients at a family medicine clinic.* One day, a school-aged brother and sister came in for their annual physicals. They were due for vaccines. Neither wanted any shots, and they were both quite upset. “You’ll do what the doctor tells you, is that clear?” ordered the mother. She and the nurse worked together to hold the sister’s arm down. But just as the nurse was about to deliver the injection, the young girl jerked her arm away and ran to the opposite corner of the room, crying. The brother then ran over and stood in front of her, his arm outstretched, guarding, and yelled “Get away! Leave her alone!” At first, the focus was on forcing them to have their shots, which were required for school. But it only made things worse. The young girl screamed, the boy fought, no one could calm them, and everyone was annoyed.
One of the senior doctors finally conceded: Let them go, we’ll have to work on this. But that family never returned.
Months later, we learned that the children had been removed from the home by the Department of Children and Families, for parental abuse. I could only imagine what had been happening.
*This vignette is based on a composite of several cases I have been involved with over the years. All potentially identifying details have been changed to protect patient privacy.
The prevalence of trauma
The CDC statistics on abuse and violence in the United States are sobering. They report that one in four children experiences some sort of maltreatment (physical, sexual, or emotional abuse). One in four women has experienced domestic violence. In addition, one in five women and one in 71 men have experienced rape at some point in their lives — 12% of these women and 30% of these men were younger than 10 years old when they were raped. This means a very large number of people have experienced serious trauma at some point in their lives.
Medical exams by definition can feel invasive. They often involve asking sensitive questions, examining intimate body parts, and sometimes delivering uncomfortable — even painful — treatments. So, it is important that healthcare providers are mindful of the fact that so many people come to that healthcare interaction with a history of trauma.
Could the case I described have been handled differently?
There have been some recent news articles about a relatively new (and improved) way for health professionals to approach patients. This is called trauma-informed care. Dr L. Elizabeth Lincoln is a primary care physician at MGH who has trained medical professionals and students about approaching patient care with an understanding of trauma. She explains: “Trauma-informed care is defined as practices that promote a culture of safety, empowerment, and healing. A medical office or hospital can be a terrifying experience for someone who has experienced trauma, particularly for childhood sexual abuse survivors. The perceived power differential, being asked to remove clothing, and having invasive testing can remind someone of prior episodes of abuse. This can lead to anxiety about medical visits, flashbacks during the visit, or avoidance of medical care.”
What does trauma-informed care look like?
The first step is to recognize how common trauma is, and to understand that every patient may have experienced serious trauma. We don’t necessarily need to question people about their experiences; rather, we should just assume that they may have this history, and act accordingly.
This can mean many things: We should explain why we’re asking sensitive questions. I might say, “I need to ask you about your sexual history, so I know what tests you may need.” We should explain why we need to perform a physical exam, especially if it involves the breasts or genitals. If someone is nervous, we can let them bring a trusted friend or family member into the room with them. I’ve had many female patients hold someone’s hand during a pelvic exam. We can tell them that if they need us to stop at any time, they can say the word. If someone refuses outright to have a certain exam or test, or if they’re upset about something (like having vaccinations), we can respond with compassion and work with them, rather than attempting to force them or becoming annoyed.
For someone who has experienced trauma, the hospital or doctor’s office can be a scary place. Dr. Lincoln explains: “Patients often do not volunteer such information about prior experiences, because of guilt or shame. Medical professionals often ask about safety in a patient’s present relationships, but few ask about past experiences. A simple question such as, “Is there anything in your history that makes seeing a practitioner or having a physical examination difficult?” or, for those with a known history of sexual abuse, “Is there anything I can do to make your visit and exam easier?” can lead to more sensitive practices geared to developing a trusting relationship. Patients can advocate for themselves by explaining to physicians their anxiety about medical visits, why this is so, and what they have found helpful or harmful in prior healthcare encounters.”
Trauma comes in many forms
It is also important to note that there are many types of trauma. A colleague of mine has a child who survived a life-threatening illness. Prior to his ICU stay, he never flinched at vaccines; since his hospitalization, any needle sticks make him extremely anxious. Another colleague describes how after years of invasive infertility treatments, and despite becoming a mother, she sobbed uncontrollably at her simple routine gynecologic exam, because it touched such a nerve of helplessness and failure. Trauma-informed care is the open-mindedness and compassion that all patients deserve, because anyone can have a history that impacts their encounter with the medical system.
We as providers need to recognize that many, many patients have a history of physical, sexual, and/or emotional abuse, as well as serious illnesses and negative experiences in the medical setting, and we need to learn to respond with empathy and understanding.All too many women recognize the signals of a urinary tract infection, or UTI: pain and burning when urinating, coupled with a frequent urge to do so. A simple change in behavior could help prevent a common UTI known as recurrent cystitis in women, according to a randomized controlled study published in JAMA Internal Medicine in October 2018. The study showed that drinking more water daily led to fewer episodes of recurrent cystitis and less need for antibiotics.
What is cystitis and what causes UTIs?
Cystitis refers to an infection in the bladder, which most women know as a urinary tract infection. Cystitis is extremely common among women, partly because female anatomy increases the risk of infection due to the proximity of the urethra to the anus. Additional risk factors for cystitis include sexual intercourse, diaphragm use, spermicides and spermicide-coated condoms, and a prior history of cystitis. Women with diabetes and those who have abnormalities of the urinary tract are also at increased risk for cystitis.
The vast majority of infections (up to 95%) are caused by one bacteria, E. coli. Signs and symptoms of an infection include pain with urination, increased frequency of urination, and an increased urge to urinate.
What is the treatment?
Cystitis is treated with antibiotics for three to five days, depending on the antibiotic used.
Can UTIs be prevented?
If you’ve ever had cystitis, you may have heard suggestions that are mostly based on anecdotal evidence. To decrease risk for cystitis, women are advised to urinate after intercourse, drink cranberry juice, drink more fluids in general, and keep the perineal area that lies between the urethra and the anus clean. Evidence is mixed on whether these steps may help prevent cystitis. This study sought to provide direct evidence of the benefits of drinking extra fluids.
What did the study tell us?
The study participants were 140 premenopausal women who experienced three or more episodes of cystitis in one year and reported that they drank less than 1.5 liters of fluids daily, which is about 6 1/3 cups. The average amount participants drank daily was a bit over a liter (1.1 liters, or about 4 1/2 cups).
The women were randomized to one of two groups. Every day, one group drank their usual amount of fluids plus an additional 1.5 liters of water. The control group drank just their usual amount of fluids. The women kept journals recording the type and amount of fluids they drank in a day. Their urine was periodically measured for volume and tested for hydration status. The study discovered that women who drank an additional 1.5 liters of water had 50% fewer episodes of recurrent cystitis, and required fewer antibiotics than women who did not drink additional fluid.
Is it safe to drink this much fluid?
While the amount of extra fluids tested in the study may seem like a lot, the Institute of Medicine recommends that women have 2.2 liters daily, which is about 9 cups. Not all of this needs to come just from water — or even fluids. Fruits and vegetables, which are part of a healthy diet, contain a lot of water.
This study used a rigorous scientific method to evaluate the benefits and risks of an inexpensive and safe anecdotal treatment. While it has been suggested that substances in cranberry juice can decrease the risk of urinary tract infection, no studies have conclusively demonstrated its benefits. Water may be the best means to increase hydration because it is inexpensive and has no calories. Although this study focused on women who had recurrent cystitis, its results could be extrapolated for a lower-risk population as well.
If you’re a woman with symptoms of cystitis, such as pain or burning with urination, increased urgency and frequency, try to drink more fluids, but also call your health care team for evaluation. A simple urine test in conjunction with the symptoms you describe may provide enough information for your health care provider to confirm an infection and start you on a brief course of antibiotics.
Better still, going forward, you may be able to decrease the chance that you will develop an infection by drinking more water daily. It’s a simple solution readily available for prevention — and now supported by evidence!6 steps toward a successful exercise resolution
Many people have decided to try the ketogenic diet for weight loss. The most recent evidence shows that reducing your carbohydrate intake to a minimum may help you shed a few pounds, at least in the first few weeks to months. However, we don’t really know whether, over the long term, achieving and maintaining ketosis is better for weight loss than other diets. Almost any intervention can cause undesirable consequences, and the ketogenic diet is no different. One of the most well-publicized complications of ketosis is something called “keto flu.”
What is keto flu?
The so-called keto flu is a group of symptoms that may appear two to seven days after starting a ketogenic diet. Headache, foggy brain, fatigue, irritability, nausea, difficulty sleeping, and constipation are just some of the symptoms of this condition, which is not recognized by medicine. A search for this term yields not a single result on PubMed, the library of indexed medical research journals. On the other hand, an internet search will yield thousands of blogs and articles about keto flu.
It is tricky to describe exactly what happens after the diet change, because we are left with only our own observations and experiences. These symptoms may not even be unique to the ketogenic diet; some of my patients describe similar symptoms after they cut back on processed foods, or decide to follow an elimination or an anti-inflammatory diet.
What causes keto flu?
Well, we don’t really know why some people feel so bad after this dietary change. Is it related to a detox factor? Is it due to a carb withdrawal? Is there an immunologic reaction? Or is this a result of a change in the gut microbiome? Whatever the reason is, it appears the symptoms attributed to the keto flu may happen, not to everyone but to some people, after “cleaning up” their diet.
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