Can knowledge impact on how we understand our patients.

Using the example of Margaret we can see how sometimes seemingly removed piece of research – combined with biographical knowledge of a person and cultural knowledge of our local area – helps us see the whole person and the bigger picture, rather than viewing the presenting problem through a purely biomedical lens.

Adverse Childhood Experiences study

The ACEs study was a landmark piece of population health research conducted in the US in the 1980s¹. It illustrates the importance of maintaining a holistic perspective and the difficulty of trying to treat people according to a diagnostic label and treating mental and physical health as separate. A large sample of patients attending an obesity clinic were asked about what the researchers termed adverse childhood experiences. In results that have been replicated many times experiencing a high degree of childhood adversity was found to correlate with a number of physical and mental health outcomes. Importantly these were not just related to mental illness but also included common physical illnesses such as cancer, obesity, diabetes and chronic pain.

Should we ask Margaret about her background? Is this relevant?

We know that adverse experiences in childhood are common and are linked with poor health. Most people however do not disclose adverse experiences to services. There may be multiple reasons why doctors do not ask about this. They may feel unsure what to do if a patient discloses a serious adverse event such as childhood abuse or might feel that they are the wrong person to speak to and they don’t have enough time. Research by the same doctors who conducted the ACEs study in the US however found that routinely enquiring about ACEs in primary care visits reduced hospital and ED attendance and was acceptable to patients although overall there is limited evidence for this approach². Patients who disclose adverse childhood experiences find it therapeutic if their care provider listens and responds empathetically and non-judgementally and do not necessarily expect further referrals or advice.

In the UK we do not routinely enquire about ACEs in primary care and doctors will have differing practices regarding this, however for someone like Margaret, understanding the context around her current health problems is might be the most important intervention we could offer her.

Some open questions and suggestions

‘We know that pain can be affected by stress. Stress is impacted by life difficulties….could be current life difficulties or things in the past. Were things tricky for you growing up?’

Or simply asking biographical questions:

• ‘Is it okay if I ask a little bit about you?’
• ‘Did you grow up around here?’
• ‘Are your family still local?’
• ‘Sometimes health problems in later life can be linked to difficulties as a child or teenager, would you say that was a difficult time for you at all?’’

References

1. Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V., & Marks, J. S. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The Adverse Childhood Experiences (ACE) Study. American journal of preventive medicine, 14(4), 245-258.
2. Ford, K., Hughes, K., Hardcastle, K., Di Lemma, L. C. G., Davies, A. R., Edwards, S., & Bellis, M. A. (2019). The evidence base for routine enquiry into adverse childhood experiences: A scoping review. Child Abuse & Neglect, 91, 131–146. https://doi.org/https://doi.org/10.1016/j.chiabu.2019.03.007