When the Doctor-Patient Divide Is a Chasm

  • Alexander Blount


For an important group of patients, the divide between themselves and their healthcare team is a chasm. These patients are variously identified in different parts of the literature, as “complex,” as “deprived,” or as “trauma victims.” Their expectations of their doctors and their doctors’ expectations of how patients should behave can be wildly at odds. Doctors and other health professionals commonly make assumptions about the ability of these patients to be active parts of their healthcare plans. Even doctors and health professionals who are interested in partnership are likely to adjust their approaches to their care, using behaviors that are less patient-centered rather than more so. For their part, these patients are less likely to trust their relationship with the members of their healthcare team and to be less confident in their own ability to improve their health states. Their likelihood of adhering to a medical regimen is correlated with their experience of the caring and support coming from their healthcare providers. Trauma informed care (TIC) can provide guideposts needed to develop a pathway to partnership and healing for these patients and their healthcare teams.


Complex patients Trauma victims Healthcare reform Disadvantaged patients Primary care Behavioral health 


  1. 1.
    Gawande A. The hotspotters. The New Yorker. Jan 24, 2011.Google Scholar
  2. 2.
    Braveman PA, Cubbin C, Egerter S, Williams DR, Pamuk E. Socioeconomic disparities in health in the United States: what the patterns tell us. Am J Public Health. 2010;100(1):186–96.CrossRefGoogle Scholar
  3. 3.
    Felitti V, Anda R, Nordenberg D, Williamson M, Spitz A, Edwards V, Koss M, Marks J. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: the Adverse Childhood Experiences (ACE) study. Am J Prev Med. 1998;14:245–58.CrossRefGoogle Scholar
  4. 4.
    Baird MA, Peek CJ, Gunn WB, Valeras A. Working with complexity in integrated behavioral health settings. In: Talen MR, Burke-Valeras A, editors. Integrated behavioral health in primary care: evaluation the evidence, identifying the essentials. New York: Springer; 2013. p. 299–324.CrossRefGoogle Scholar
  5. 5.
    Bodenheimer T, Berry-Millett R. Care management of patient with complex health care needs. Robert Wood Johnson Foundation. 2009.
  6. 6.
    Johns Hopkins University. Johns Hopkins University ACG system: white paper – technical. 2012.
  7. 7.
    Noyes K, Liu H, Temkin-Greener H. Medicare capitation model, functional status, and multiple comorbidities: model accuracy. Am J Manag Care. 2008;14(10):679–90.PubMedPubMedCentralGoogle Scholar
  8. 8.
    Smith SM, Soubhi H, Fortin M, Hudon C, O’Dowd T. Managing patients with multimorbidity: systematic review of interventions in primary care and community settings. BMJ. 2012;345:1–10.Google Scholar
  9. 9.
    Von Korff M, Wagner EH, Saunders K. A chronic disease score from automated pharmacy data. J Clin Epidemiol. 1992;45:2.Google Scholar
  10. 10.
    Pratt R, Hibberd C, Cameron IM, Maxwell M. The Patient Centered Assessment Method (PCAM): integrating the social dimensions of health into primary care. J Comorb. 2015;5:110–9.CrossRefGoogle Scholar
  11. 11.
    Long P, Abrams M, Milstein A, Anderson G, Apton KL, Dahlberg ML, Whicher D, editors. Effective care for high-need patients: opportunities for improving outcomes, value and health. Washington, DC: National Academy of Medicine; 2017.Google Scholar
  12. 12.
    Newton WP, Lefebvre A. Is a strategy focused on super-utilizers equal to the task of health care system transformation? No. Ann Fam Med. 2015;13:8–9.CrossRefGoogle Scholar
  13. 13.
    Katon WJ, Egede LE. Major depression in individuals with chronic medical disorders: prevalence, correlates and association with health resource utilization, lost productivity and functional disability. Gen Hosp Psychiatry. 2003;29:409–16.Google Scholar
  14. 14.
    Melek S, Norris D. Chronic conditions and comorbid psychological disorders. Milliman research report. 2008.
  15. 15.
    Ford JD, Trestman RL, Steinberg K, Tennen H, Allen S. Prospective association of anxiety, depressive, and addictive disorder with high utilization of primary, specialty and emergency medical care. Soc Sci Med. 2004;58:21456–2148.CrossRefGoogle Scholar
  16. 16.
    Frankel SA, Bourgeois JA, Erdberg P. Comprehensive care for complex patients: the medical-psychiatric coordinating physician model. New York: Cambridge University Press; 2013.Google Scholar
  17. 17.
    Maxwell M, Hibberd C, Pratt R, Peek CJ, Baird M. Patient centered assessment method. 2013.
  18. 18.
    Peek CJ, Baird MA, Coleman E. Primary care for patient complexity, not only disease. Fam Syst Health. 2009;27:287–302.CrossRefGoogle Scholar
  19. 19.
    Yoshida S, et al. Validity and reliability of the Patient Centered Assessment Method for patient complexity and relationship with hospital length of stay: a prospective cohort study. BMJ Open. 2017;7:e016175.CrossRefGoogle Scholar
  20. 20.
    Adler NE, Boyce T, Chesney MA, Cohen S, Folkman S, Kahn RL, Syme SL. Socioeconomic status and health: the challenge of the gradient. Am Psychol. 1994;49:15–24.CrossRefGoogle Scholar
  21. 21.
    Myers HF. Ethnicity and socio-economic status-related stressed in context: an integrative review and conceptual model. J Behav Med. 2009;32:9–19.CrossRefGoogle Scholar
  22. 22.
    Hatch SL, Dohrenwend BP. Distribution of traumatic and other stressful life events by race/ethnicity, gender, SES and age: a review of the research. Am J Community Psychol. 2007;40:313–32.CrossRefGoogle Scholar
  23. 23.
    Geronimus AT, Hicken M, Keene D, Bound J. “Weathering” and age patterns of allostatic load scores among Blacks and Whites in the United States. Am J Public Health. 2006;96:826–37.CrossRefGoogle Scholar
  24. 24.
    Sacks V, Murphey D. The prevalence of adverse childhood experiences nationally, by state, and by race or ethnicity. Bethesda: Child Trends; 2018.Google Scholar
  25. 25.
    Wade R, Shea JA, Rubin D, Wood J. Adverse childhood experiences of low-income urban youth. Pediatrics. 2014;134:e13–20.CrossRefGoogle Scholar
  26. 26.
    Dong M, Anda RF, Felitti VJ, Dube SR, Giles WH. The relationship of exposure to childhood sexual abuse to other forms of abuse, neglect and household dysfunction during childhood. Child Abuse Negl. 2003;27:625–39.CrossRefGoogle Scholar
  27. 27.
    Anderson CM, Teicher MH, Polcari A, Renshaw PI. Abnormal T2 relaxation time in the cerebellar vermis of adults sexually abused in childhood: potential role of the vermis in stress-enhanced risk for drug abuse. Psychoneuroendocrinology. 2002;27:231–44.CrossRefGoogle Scholar
  28. 28.
    Carrion VG, Steiner H. Trauma and dissociation in delinquent adolescents. J Am Acad Child Adolesc Psychiatry. 2000;39:353–9.CrossRefGoogle Scholar
  29. 29.
    De Bellis M, Thomas L. Biologic findings of post-traumatic stress disorder and child maltreatment. Curr Psychiatry Rep. 2003;5:108–17.CrossRefGoogle Scholar
  30. 30.
    Perry BD, Pollard R. Homeostasis, stress, trauma, and adaptation. A neurodevelopmental view of childhood trauma. Child Adolesc Psychiatr Clin N Am. 1998;7:33–51.CrossRefGoogle Scholar
  31. 31.
    Sanchez MM, Ladd CO, Plotsky PM. Early adverse experience as a developmental risk factor for later psychopathology: evidence from rodent and primate models. Dev Psychopathol. 2001;13:419–49.CrossRefGoogle Scholar
  32. 32.
    Musselman DL, Evans DL, Nemeroff CB. The relationship of depression to cardiovascular disease. Arch Gen Psychiatry. 1998;55:580–92.CrossRefGoogle Scholar
  33. 33.
    Anda RF, Felitti VJ, Bremner JD, Walker JD, Whitfield C, Perry BD, Dube SR, Giles WH. The enduring effects of abuse and related adverse experiences in childhood: a convergence of evidence from neurobiology and epidemiology. Eur Arch Psychiatry Clin Neurosci. 2006;256:174–86.CrossRefGoogle Scholar
  34. 34.
    van Reekum R, Streiner DL, Conn DK. Applying Bradford Hill’s criteria for causation to neuropsychiatry: challenges and opportunities. J Neuropsychiatry Clin Neurosci. 2001;12:318–25.CrossRefGoogle Scholar
  35. 35.
    Stein MB, McQuaid JR, Pedrelli P, Lenox R, McCahill ME. Posttraumatic stress disorder in the primary care medical setting. Gen Hosp Psychiatry. 2000;22:261–9.CrossRefGoogle Scholar
  36. 36.
    Peek CJ, Baird MA. Point-of-care complexity assessment helps primary care clinicians identify barriers to improved health and craft integrated care plans. AHRQ Innovations Exchange. 2009.Google Scholar
  37. 37.
    O’Dowd TC. Five years of heartsink patients in general practice. BMJ. 1988;297:528–30.CrossRefGoogle Scholar
  38. 38.
    Cunningham PJ. Why even health low-income people have greater health risks than higher-income people. To the Point (blog), Commonwealth Fund. 2018.Google Scholar
  39. 39.
    Mautner DB, Pang H, Brenner JC, Shea JA, Gross KS, Frasso R, Cannuscio CC. Generating hypotheses about care needs of high utilizers: lessons from patient interviews. Popul Health Manag. 2013;16:S26–33.CrossRefGoogle Scholar
  40. 40.
    Caruso M. The patient-physician relationship from the perspective of economically disadvantaged patients (Dissertations & Theses). 361. 2017.
  41. 41.
    Bernheim SM, Ross JS, Krumholz HM, Bradley EH. Influence of patients’ socioeconomic status on clinical management decisions: a qualitative study. Ann Fam Med. 2008;6(1):53–9.CrossRefGoogle Scholar
  42. 42.
    American Psychologic Association, APA Working Group on Stress and Health Disparities. Stress and health disparities: contexts, mechanisms, and interventions among racial/ethnic minority and low-socioeconomic status populations. 2017. Retrieved from
  43. 43.
    Agency for Healthcare Research and Quality (AHRQ). National healthcare quality and disparities report. Rockville. 2016. July 2017. AHRQ Pub. No. 17-0001.Google Scholar
  44. 44.
    Willems S, De Maesschalck S, Deveugele M, Derese A, De Maeseneer J. Socio-economic status of the patient and doctor-patient communication: does it make a difference? Patient Educ Couns. 2005;56:139–46.CrossRefGoogle Scholar
  45. 45.
    Fiscella K, Goodwin MA, Strange LC. Does patient educational level effect visits to family physicians? J Natl Med Assoc. 2002;94:157–65.PubMedPubMedCentralGoogle Scholar
  46. 46.
    Garrison WT, Bailey EN, Garb J, Ecker B, Spencer P, Sigelman D. Psychiatr Serv. 1992;43:489–93.CrossRefGoogle Scholar
  47. 47.
    Peek ME, Odoms-Young A, Quinn MT, Gorawara-Bhat R, Wilson SC, Chin MH. Race and shared decision-making: perspectives of African Americans with diabetes. Soc Sci Med. 2010;71:1–9.CrossRefGoogle Scholar
  48. 48.
    Ahern J, Stuber J, Galea S. Stigma, discrimination and the health of illicit drug users. Drug Alcohol Depend. 2007;88:188–96.CrossRefGoogle Scholar
  49. 49.
    Marteau TM, Riordan DC. Staff attitudes towards patients: the influence of causal attributions for illness. Br J Clin Psychol. 1992;31:107–10.CrossRefGoogle Scholar
  50. 50.
    Violan C, Foguet-Boreu Q, Flores-Mateo G, Salisbury C, Blom J, et al. Prevalence, determinants and patterns of multimorbidity in primary care: a systematic review of observational studies. PLoS One. 2014;9(7):e102149. Scholar
  51. 51.
    Barnett K, Mercer SW, Norbury M, Watt G, Wyke S, Guthrie B. Epidemiology of multimorbidity and implications for health care, research, and medical education a cross-sectional study. Lancet. 2012;380:37–43.CrossRefGoogle Scholar
  52. 52.
    Danese A, Moffit TE, Harrington H, et al. Adverse childhood experiences and adult risk factors for age-related disease. Arch Pediatr Adolesc Med. 2009;163:1135–43.CrossRefGoogle Scholar
  53. 53.
    Löwe B, Kroenke K, Spitzer R, Spitzer C. Trauma exposure and posttraumatic stress disorder in primary care patients. J Clin Psychiatry. 2011;72:304–12.CrossRefGoogle Scholar
  54. 54.
    Larkin H, Shields J, Anda R. The health and social consequences of adverse childhood experiences (ACE) across the lifespan: an introduction to prevention and intervention in the community. J Prev Interv Community. 2012;40:263–70.CrossRefGoogle Scholar
  55. 55.
    Edwards T, Stern A, Clarke DD, Ivbijaro G, Kasney LM. The treatment of patients with medically unexplained symptoms in primary care: a review of the literature. Ment Health Fam Med. 2010;7:209–21.PubMedPubMedCentralGoogle Scholar
  56. 56.
    Center for Disease Control and Prevention National Center for Health Statistics. Diabetes prevalence and glycemic control among adults aged 20 and over, by sex, age, and race and Hispanic origin: United States, selected years 1988–1994 through 2011–2014 [trend tables: table 40]. Health, United States, 2015 – poverty. 2015. Retrieved from
  57. 57.
    Adler NE, Newman K. Socioeconomic disparities in health: pathways and policies. Health Aff. 2002;21(2):60–76.CrossRefGoogle Scholar
  58. 58.
    Roberts AL, Agnew-Blais JC, Spiegelman D, Kubzansky LD, Mason SM, Galea S, Hu FB, Rich-Edwards JW, Koenen KC. Posttraumatic stress disorder and incidence of type 2 diabetes mellitus in a sample of women: a 22-year longitudinal study. JAMA Psychiat. 2015;72:203–10.CrossRefGoogle Scholar
  59. 59.
    Su S, Wang X, Pollock JS, Treiber FA, Xu X, Snieder H, McCall WV, Stefanek M, Harshfield G. Adverse childhood experiences and blood pressure trajectories from childhood to young adulthood: the Georgia Stress and Heart study. Circulation. 2015;131:1674–81.CrossRefGoogle Scholar
  60. 60.
    Sumner JA, Kubzansky LD, Elkind MSV, Roberts AL, Agnew-Blais J, Chen Q, Cerdá M, Rexrode KM, Rich-Edwards JW, Spiegelman D, Suglia SF, Rimm EB.Google Scholar
  61. 61.
    Mersky JP, Janczewski CE, Nitowski JC. Poor mental health among low-income women in the U.S.: the roles of adverse childhood and adult experiences. Soc Sci Med. 2018;206:14–21.CrossRefGoogle Scholar
  62. 62.
    Herman DB, Susser ES, Struening EL, Link BL. Adverse childhood experiences: are they risk factors for adult homelessness? Am J Public Health. 1997;87:249–55.CrossRefGoogle Scholar
  63. 63.
    Breslow N. Gender differences in trauma and posttraumatic stress disorder. J Gend Specif Med. 2002;5:34–40.Google Scholar
  64. 64.
    Uddin M, Aiello AE, Wildman DE, Koenen KC, Pawelec G, de Los Santos R, Goldmann E, Galea S. Epigenetic and immune function profiles associated with posttraumatic stress disorder. Proc Natl Acad Sci. 2010;107:9470–5.CrossRefGoogle Scholar
  65. 65.
    Street RL. Communicative styles and adaptations in physician-parent consultations. Soc Sci Med. 1992;34:1155–63.CrossRefGoogle Scholar
  66. 66.
    Fox S, Chelsa C. Living with chronic illness: a phenomenological study of the health effects of the patient-provider relationship. J Am Acad Nurse Pract. 2008;20:109–17.CrossRefGoogle Scholar
  67. 67.
    Green BL, Saunders PA, Power E, et al. Trauma-informed medical care: CME communication training for primary care providers. Fam Med. 2015;47:7–14.PubMedPubMedCentralGoogle Scholar
  68. 68.
    Purkey E, Patel R, Phillips SP. Trauma-informed care: better care for everyone. Can Fam Physician. 2018;64:170–2.PubMedPubMedCentralGoogle Scholar
  69. 69.
    Raja S, Hasnain M, Vadakumchery T, Hamad J, Shah R, Hoersch M. Identifying elements of patient-centered care in underserved populations: a qualitative study of patient perspectives. PLoS One. 2015;10(5):e0126708.CrossRefGoogle Scholar
  70. 70.
    Netting FE, Williams FG. Geriatric case managers: integration into physician practices. Care Manag J. 1999;1(1):3–9.CrossRefGoogle Scholar
  71. 71.
    Frankel SA, Bourgeois JA. Integrated care for complex patients. New York: Springer; 2018.CrossRefGoogle Scholar
  72. 72.
    Dorr DA, Wilcox AB, Brunker CP, Burdon RE, Donnelly SM. The effect of technology-supported, multidisease care management on the mortality and hospitalization of seniors. J Am Geriatr Soc. 2008;56(12):2195–202.CrossRefGoogle Scholar
  73. 73.
    Nurius PS, Logan-Greene P, Green S. Adverse childhood experiences (ACE) within a social disadvantage framework: distinguishing unique cumulative, and moderated contributions to adult mental health. J Prev Interv Community. 2012;40:278–90.CrossRefGoogle Scholar


    For Patients Concerning Trauma

    1. Gift from Within. A site for survivors of trauma and victimization.
    2. National Center for Posttraumatic Stress Disorder,
    3. National Child Traumatic Stress Network,
    4. Sidran Institute. For Survivors and Loved Ones – printable handouts.

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  • Alexander Blount
    • 1
  1. 1.Department of Clinical PsychologyAntioch University New EnglandKeeneUSA

Personalised recommendations