I want to write about something we don't talk about enough in NP training: trauma-informed care. Not as a checkbox or a hospital initiative, but as a fundamental shift in how we sit with patients.
By some estimates, the majority of adults in primary care have experienced significant trauma — abuse, violence, loss, medical trauma, neglect, war, displacement. You will not know this from looking at them. They will not tell you on the intake form. But it shapes how they show up in your office.
Trauma-informed care is not a specialty. It is a way of being with people that should apply to every patient you see.
What Trauma Does to a Patient in Your Office
A patient with a history of trauma may:
- Avoid the pelvic exam, or freeze during it
- Cancel appointments repeatedly without explanation
- Become flooded, dissociated, or shut down when discussing certain topics
- Be hyper-vigilant — scanning the room, reluctant to undress, watching your hands
- Push back at perceived authority figures, including you
- Have somatic complaints with no clear physical cause
- Use substances or food in ways that are coping mechanisms
- Distrust the healthcare system in ways that feel "non-adherent" to you
These behaviors are not character flaws. They are survival strategies that worked once. They may not be serving the patient now, but they are not bad behavior.
The Shift in How You Sit
Most of what trauma-informed care looks like is small. It is the way you sit, the way you ask, the way you let the patient be in charge of more than they're used to being.
Knock before entering
Always. Wait for a response. Don't surprise the patient.
Sit at eye level
Standing over a vulnerable patient activates a power dynamic. Sit.
Ask permission before touching
"I'm going to listen to your heart now. Is that okay?" "I'd like to do an abdominal exam. Can I lift your gown?" "I'm going to use this stethoscope on your back. May I?"
This costs you 30 seconds. It gives the patient back the agency that previous experiences took from them.
Explain before you do
"I'm going to press here. It may feel cold. Tell me if anything is tender."
Watch for signs of overwhelm
If the patient's body language changes — they go silent, their breathing changes, their eyes glaze — pause. "How are you doing? Do you need a moment?"
Sometimes the right move is to stop the exam, let the patient regroup, and try again later. That's not a failed visit. That's a successful one.
Truth: The provider who pauses when a patient's nervous system is overwhelmed will earn more trust in one visit than the provider who pushes through earns in five.
The Pelvic Exam
This deserves its own paragraph. The pelvic exam is one of the most common trauma-activating events in primary care. For many women, it is the most vulnerable thing they do in their healthcare year.
What helps:
- Explain the entire exam before any clothes come off
- Let the patient choose whether to have a chaperone
- Tell them they can stop at any moment, and you will stop immediately
- Don't fill silence with chatter — let them be quiet if they want
- Warm the speculum
- Don't make small talk about the procedure ("oh this won't take long")
- After: check in. "How was that for you?"
If a patient declines a pelvic exam, respect it. There are alternatives (self-collected HPV testing in some settings). The pelvic is not the patient's relationship to you.
What Trauma-Informed Care Is Not
It is not asking every patient to disclose their trauma. The disclosure is theirs to control. You do not need to know the story to sit with the person.
It is not avoiding hard topics. You will still address weight, substances, sexual health. You will just do it with more care.
It is not therapy. You are not the therapist. If a patient is processing trauma, you can refer to mental health colleagues while still being a steady presence in primary care.
The ACE Score
The Adverse Childhood Experiences (ACE) study showed that childhood adversity predicts adult chronic disease. Higher ACE scores correlate with higher rates of heart disease, autoimmune disease, depression, and substance use.
You don't need to screen formally for ACEs in every visit. You do need to know that the patterns of chronic disease you are managing often have roots that go back decades, and that medication alone will not solve what trauma created.
Your Own Trauma
I'll say this gently. Many providers are themselves trauma survivors. If you find certain patient presentations activating for you — the abuse survivor, the substance user, the patient who reminds you of a family member — notice. Don't ignore.
Your own care is part of the work. Therapy, peer supervision, processing groups for healthcare workers — these are not luxuries. They are what allow you to keep showing up with steadiness.
Building Trust Over Time
Trauma-informed care is not one visit. It is the slow accumulation of safe encounters over months and years. The patient who flinched at the BP cuff in visit one may, three years in, tell you why. They may also start taking the medication, addressing the substance, coming in earlier when something is wrong.
The trust you build is itself therapeutic. Don't underestimate it.
The Long Practice
For one week, practice this: ask permission before every touch. Notice what shifts in the room. Notice which patients exhale slightly. Notice your own pace.
This is not extra work. This is the work. It is what makes a primary care visit healing instead of just clinical.