Assessing Resident Confidence in Screening and Intervening with Patients’ ACE Scores

10-11-2018 09:30

Assessing Resident
Confidence in
Screening and
Intervening with
Patients’ ACE Scores

Background of Original ACE Study
● Department of Preventive Medicine, Kaiser Permanente in San Diego
● Help understand how ACEs might affect health later in life
● Track medical charts prospectively to analyze clinical courses forward in
time
● 2 groups of 13,000- 70% agreed to participate
○ 26 to 90s (average 57y/o)
○ 50% men and 50% women
○ 80% white (including Hispanic), 10% Asian, 10% Black
○ Mostly middle class
Outcomes of the Original ACE Study
● No phone calls from patients for the doctors doing the original ACE study
at Kaiser in 3 years
● A number of patient compliments were received by the researchers
● A small collection of thank you letters were sent to the researchers
○ “Thank you for asking. I feared I would die and no one would ever know what had
happened.”
Why are ACE Scores Important to Patient Health?
● High ACE scores associated with:
○ distinct increase in likelihood of CAD in adult life, even in the absence of Framingham risk
factors
○ likelihood of long term smoking
● Interviews with obese and sexually abused patients led to
discovering long-term medical effects of seriously troubled
childhoods that were never documented.

“50% of practicing physicians and 30% of resident physicians reported
confidence to screen, yet screening is much lower for practicing
physicians and almost non existent for resident physicians.” Adverse
Childhood Experiences: Survey of Resident Practice, Knowledge, and
Attitude
January 2017

Implementing ACE at La Grange Memorial Hospital
● July 2017: presentation given to residents and faculty about original ACE
study
● Every new patient and well visit over 17 would be given the ACE
questionnaire beginning in July

Initial ACE Implementation Protocol
● Role play with program director as the patient
● Patients with positive questionnaires would be asked “How are those
events still affecting you today?”
● Patient would be listened to, made to feel accepted, and given feedback
that noted their courage and allowed for a better understanding of their
problems.

Initial Reluctances
● “There is not enough time to ask about history of childhood physical or
sexual abuse. Even a 5 minute intervention takes 30% of my time.”
● “I feel uncomfortable inquiring about psychosocial issues; I’m afraid I may
say the wrong thing.”
● I’m concerned that taking a history of childhood physical or sexual abuse
may re-traumatize my patient. I fear I may harm the patient and upset
them.”
● “There is little I can do to help those patients who have revealed a history
of childhood physical or sexual abuse.”

March 2018 Resident Feedback
“The ACE questionnaire helps to educate patients, and helps to identify whether it stems
from original traumatic experience or whether it is a slow and gradual process”
“It opens doors for the patients.”
“I use the questionnaire to help explain how these mentally stressful events cause
physical issues when I perform OMT.”
“I have found that continuing to give the writing assignment offers more structure and goal
orientation for my patient”
“I believe the questionnaire helps patients understand their present problems”
“I now know what to expect with certain patients with their visits moving forward and
better understand what they feel physically and emotionally.”
“The patient stated they have now a more positive viewpoint of
themselves.”
“I’ve had multiple times patients cry on me, yet admit they feel better after the intervention
and thank me for asking.”
Not one resident reported a negative experience or any patient decompensating due to the ACE
intervention.

Initial Faculty Focus Group April 2018
Identified main barriers to screening:
● Not enough time to ask about history of childhood physical or sexual abuse
● Competing multiple primary care recommendations
● Uncomfortable inquiring about psychosocial issue
-“By screening with the ACE questionnaire, several of the other problems would also be addressed.”
-Faculty advised NOT to reflexively refer to counseling with psychologist upon upon review of + ACE
questionnaire; instead, faculty requested the residents have scripts with different brief interventions
to give to a patient with + ACE score.

Revision to ACE Implementation Protocol
● Residents educated on how to respond to positive ACE score with a brief
feedback:
○ “I respect the courage it took to answer “yes” How does that adverse event affect you
today? We are all taught to love people and use things. It was totally wrong to treat you as
a thing. There is only one piece of good news regarding childhood adversity and that is
you can fully recover. I want you to complete the writing assignment before your
follow-up appointment”
● Residents educated on how to provide final feedback:
○ “Remember, you never have to talk about what happened in the past with anyone. We
know there is a direct relationship between these experiences and a person’s physical
health; we’ll explore these next time”

Real Patient Case: Anorexia
Main past problems:
● 20yo female with amenorrhea, low Vitamin D and low BMI
● Touched by her uncle, followed up with counseling, reports parents knew this
happened
● Lost virginity at 12. Boy was same age; she feels that was another traumatic
experience
Current problem:
● Not over her past problems of abuse as it seems to have manifested into her not
taking care of her own body
● She was used twice in her life, once when she was touched by her uncle and
secondly when she lost her virginity.
● Feels she can’t grow up; feels stuck at age 20 mainly due to not having her period
Real Patient Case: Anorexia
Plan:
● Patient feels she never gave anorexia program at Alexian Brothers a chance and
would like to see it through.
● Discussed having a peer group is essential for disordered eating behaviors
Result:
● Added youth screening for adolescents under 18 with CYW ACE-Q Child

Real Patient Case: T2DM
Main past problems:
● 53 yo female with uncontrolled T2DM
● Molested by family member when she was younger and never mentioned it to
anyone in her life prior to office visit for 3 month diabetes follow up
Current problem:
● She has treated her disease of diabetes like she has treated her experience of
sexual abuse: by suppressing it and ignoring the problems.
● Result of uncontrolled diabetes and unresolved trauma from prior sexual abuse
Real Patient Case: T2DM
Plan:
● Better compliance with diabetic medications and diet regimen coupled with writing
assignment and counseling
Result:
● Decrease in HBa1c in part due to use of ACE
● When she was asked if she were to live her life over again what change would she
make, “she said she would keep no secrets.”

Evolution of Data Collection- July 2018
● All experiences with the ACE intervention were positive
● Recognized that it is vital for the mental and physical health of the patient
that doctors are trained and feel confident in screening and intervening
● 2021 intern class gave a baseline assessment of how confident they feel
in screening and intervening before any training on a scale of 1 to 10
● Baseline class average was 7.8 out of 10
● Follow up assessment of confidence will be done in the future to assess
training effectiveness

Class of 2021 Feedback
Resident: “The patient seemed grateful and had a sigh of relief.”
Patient: “Thank you for giving me these options to help treat me for my anxiety.”
Patient: “I appreciate you focusing my history and not just the medical stuff. Thank
you for the writing assignment”
“This is the first time I have been asked about this. This is really cool that
you guys ask me about this. Thank you for asking.”
No complaints or negative interactions reported

Faculty Assessment- September 2018
“Senior residents are feeling more confident in screening. The biggest obstacle is time to
discuss history.”
“I feel we are getting better with assisting residents and feel more comfortable inquiring
about psychosocial issues as well”
“Residents seem more aware of ACE issues, they now have a template for a structured
response to + ACE and seem to be using it.”
“Residents seem more confident in finding time to respond to + ACE screenings and
creating a follow up plan. They don't seem as overwhelmed by time required to screen
and respond, and they are comfortable asking patient to follow up.”

What is next?
● Continue training residents to become confident in screening and
intervening
● Continue to educate the residents about the importance of the ACE
intervention to improve screening rates
● Encourage other residency programs to screen and intervene in their own
patients with + ACE scores on the initial visit so other medical problems
can be addressed

Closing comments from Dr. Cahill
References
Cornelius, Van Niel. et al. “Adverse Events in Children: Predictors of Adult
Physical and Mental Conditions.” Journal of Developmental and Behavioral
Pediatrics 35.8 (2014): 549-51
Felitti, V. Anda, R. “The Lifelong Effects of Adverse Childhood Experiences.”
Chadwick’s Child Maltreatment Vol 2. CH 10. (2014): 203-15
Seligman, M. “Shedding the Skins of Childhood.” What You Can Change and
What You Can’t (2007) 225-43
Tink, W. Tink, J. et al. “Adverse Childhood Experiences: Survey of Resident
Paractice, Knowledge, and Attitude.” Family Medicine 49.1 (2017): 7-13

Author(s):Thomas Cahill, PhD,Nicholas Yunez MD and David Mohr DO
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