The core principles of this care include the four R’s:

1. Realizing the widespread impact of trauma.

2. Recognizing signs and symptoms of trauma, including in patients and their families and in staff and clinical team members.

3. Responding by fully integrating knowledge about trauma into policies, procedures, and practices.

4. Seeking to actively resist Retraumatization.

It is important to treat all patients using TIC because many patients experience violence and they often don't feel comfortable disclosing their past to medical professionals; therefore, healthcare professionals need to act as if every patient is a survivor of trauma.

Pre-visit

Review the patient’s chart for trauma-related documentation to avoid asking the patient to repeat this history and to improve visit preparation

Encounter

Be seated to decrease the existing power differential between physicians and patients; encourage residents, students, or other present staff to also be seated

Offer options for the patient to be interviewed alone (e.g., have support staff care for accompanying children)

Emphasize confidentiality as the encounter begins

Prepare the patient for what to expect with regard to history, examination, and any procedures

Make the patient aware that you may be taking notes during the encounter to ensure thoroughness in addressing all questions and concerns

Explain the rationale for sensitive questions, such as when eliciting substance use and sexual history

If a language interpreter is being used, when possible, ask if the patient has a gender and/or cultural preference for the interpreter

Physical examination

Ask patients if there are any parts of the physical examination that they feel anxious about, and if there is anything you can do to help make the physical examination feel more comfortable

Ask the patient to shift his or her clothing out of the way instead of doing it yourself (e.g., lifting his or her own shirt for an abdominal examination)

Ask the patient for permission before conducting each section of physical examination (e.g., when moving from heart to lung examination)

Invasive examinations and procedures

Determine whether alternate measures can be taken for certain examinations (e.g., offering self-insertion of swabs for vaginitis workup instead of speculum examination)

Ask whether the patient would like to have another person in the room for support

Describe the entire procedure, obtain consent, and set up the appropriate equipment (e.g., remove packaging from swabs and Papanicolaou smear containers, and apply lubrication on scopes or speculums) before the patient removes clothing

Describe ways in which the examination may interact with senses (e.g., “You may hear clicks when the speculum is opened”; “The lubrication on the speculum/anoscope may feel cool”; or “You may experience a gagging sensation with the throat swab”)

Discuss in advance that the patient can dictate the pace of the examination and can signal to you (through verbal or nonverbal signals) if there is any discomfort or a break is needed

Offer speculum self-insertion

Practice suggestive instead of instructive language (e.g., replace the phrase “Take a deep breath and relax” with “Some people find it helpful to take a deep breath during this part of the examination”)

Have postprocedural supplies ready to provide to patient (e.g., tissues or wipes following speculum examination or anoscope)

Imaging

Alert the patient in advance if imaging may be invasive (e.g., transvaginal or scrotal ultrasonography), constrictive (e.g., magnetic resonance imaging), or weighted (e.g., lead aprons for chest radiography)

Referrals

Notify referrals in advance regarding relevant trauma history so colleagues are appropriately prepared

Post-visit

Provide written after-care instructions and follow-up plan in case patients experience dissociation or distracting anxiety during the visit

Choose sensitive language for diagnoses in visit summaries that are provided to patients and in documentation

Reference: Ravi, A., & Little, V. (2017). Providing trauma-informed care. American Family Physicians, 95(10), 655-657