Seeing the Whole Patient

May 31, 2022

Using the Brain Story to Understand and Support Vulnerable Patient Populations with Complex Needs

 

Dr. Francesco Mosaico, MD, CCFP (AM), Medical Director, Boyle McCauley Health Centre and Edmonton Isolation Facility, Assistant Clinical Professor, Faculty of Medicine and Dentistry, University of Alberta

Dr. Serena Jenkins, PhD, Scientific Associate, Palix Foundation

 

Anita^* was referred to the Boyle McCauley Health Centre (BMHC) in Edmonton. At an emergency department visit several months earlier, a chest x-ray revealed a lesion that was suspicious for cancer, but she had not followed up. Another x-ray and a CT scan revealed a tumour the size of half a grapefruit on her back, and she was booked for a biopsy and several additional procedures.

However, she missed almost all her appointments, even when they were rescheduled.

Eventually, Dr. Mosaico^** shared his concerns that she was neglecting her health. Anita looked at her physician and shared: “Look, I don’t really talk to anyone about what I’m about to tell you. But I trust you, and I think it might have something to do with why it’s hard for me to do all this stuff.”

She shared the terrible abuse she experienced as a young girl in her family of origin. After being placed in foster care, the abuse continued for years in what should have been a safe environment. At the age of 14, she felt her best option was to run away and live on the streets. While homeless, Anita befriended a woman whom she remembered as being kind and nurturing. One evening Anita was excited to learn that her friend’s boyfriend had arranged for her to spend a night in a hotel, an experience she had never had. Anita later learned that the man was actually her friend’s pimp. Anita answered a knock at her hotel room door to find an unfamiliar older man. She initially fended off his sexual advances, but after he covered her face with a pillow and threatened to suffocate her if she didn’t comply, she stopped fighting.

“After it was over, I didn’t know what to do, so I just kind of pushed it to the back of my mind and tried to forget about it...like it hadn’t happened. The same thing happened to me again a few years later and so I just pushed that to the back of my mind too, like it hadn’t happened...I didn’t know what else to do”.

Anita paused before continuing, “So, when I was told that I had a spot on my x-ray that was probably cancer, I just pushed it to the back of my mind, like all the other stuff. I’m not sure how to deal with it...I think that’s why I keep missing all these appointments…do you understand?”

This dramatically shifted Dr. Mosaico’s understanding of his patient. Moving forward, they searched for approaches to her health that improved her quality of life while protecting her emotional and psychological safety.

A few years after Anita’s death, Dr. Mosaico was at an AFWI symposium listening to the principal co-investigator of the Adverse Childhood Experiences (ACE) study, Dr. Robert Anda. He shared that the key finding of the study was a strong relationship between developmental trauma and multiple risk factors for poor health outcomes in adulthood. Dr. Mosaico considered the implications and applications of this study in his clinical work and how helpful the lecture would have been at the start of his medical training.

BMHC then participated in a two-year AFWI-sponsored initiative, “Change in Mind”. The aim was to develop organizational approaches to embed this science into every aspect of service delivery.

Over 225 BMHC clients learned about the science during one-on-one encounters with a member of the interdisciplinary team that supported them. They also completed the ACEs survey. Whereas the prevalence of high ACE scores in the general population hovers around 12%, it was 93% amongst the BMHC clients. For most clients, discussing their trauma alleviated deeply entrenched feelings of self-loathing, worthlessness, and guilt. The brain science helped them to understand that they were not responsible for many of the barriers they faced to succeeding in society. Many described that having their health team catch a glimpse of the unseen and impossibly heavy burden of their trauma engendered a deep sense of trust in the supports that they were being offered, and they became more open to new approaches to optimizing their wellness.

While BMHC staff had always understood that the client population it served had experienced severe trauma, seeing this verified through the survey results was troubling. However, it also fuelled the effort to seek more effective ways to foster resilience, hope, and improved health outcomes. The understanding and application of the Brain Story transformed the approaches used at BMHC in their work with vulnerable clients.

 

*Client’s real name has not been used.

**Dr. Francesco Mosaico has been a staff physician at the Boyle McCauley Health Centre (BMHC) since 2007. The BMHC’s mission is to provide client-centred, interdisciplinary care to individuals who face challenges including, but not limited, to homelessness; socioeconomic marginalization; complex psychiatric and medical concerns, including substance use disorders; and recidivism in the criminal justice system.