By Kate Murphy
Can a shift in posture or tone of voice be a symptom of disease? What about a doting grandmother?
Though harder to discern than swollen glands or an irregular heartbeat, certain behaviors, relationships, and feelings are equally strong indicators of physical health. Dorothy Trevino, associate professor in UTMB's Department of Family Medicine, has spent almost twenty years training students and resident physicians to recognize “psychosocial factors” so they can make more accurate diagnoses and provide more effective treatment.
Though research repeatedly has demonstrated a reciprocal relationship between psychosocial issues and physical health, traditionally physicians have tended to focus solely on medical problems. They treat the corporeal manifestations of illness but often fail to address the psychological, cultural, or emotional aspects. For example, job stress and abusive relationships are strongly correlated with high blood pressure and gastrointestinal disorders. Depression begets inflammation, and vice versa. “Psychosocial factors may be seen as outside medicine, but anything that affects health is medicine,” says Trevino, who has a doctorate in clinical social work.
A fter a month-long rotation under her supervision, many family medicine residents come to agree. Family medicine is one of the few specialties that require residents to learn how to address patients' psychosocial needs. “Some are more resistant to learning the psychosocial-behavioral side at first,” says physician Peter Gosselink, who completed his family medicine residency last June and now practices in Marble Falls, Texas, “but in the end everybody thinks what they learn from Dorothy is invaluable.”
Particularly instructive, according to residents, are the tips Trevino offers while observing them with their patients. “Every Friday we'd meet with two of our most difficult cases,” says Gosselink. “With the patient's consent, Dorothy would be watching from a remote location” via closed-circuit television. A telephone link enabled Trevino to call in and give the residents pointers. “She might tell me to pay attention to certain cues like a change in posture or tone of voice when I said something about the patient's job,” which with more questioning he discovered was debilitating shift work, says Gosselink. Or maybe to find out more about a diabetic patient's grandmother, who, he later learned, “thought to love is to give you a cookie,” he says.
Helping patients recognize and resolve problems at work or within their families can be central to improving if not curing their physical ailment. “But you have to see it to address it,” says Trevino. “Doctors are usually so rushed that it may be difficult for them to slow down and really see what's going on with the patient.” Her role, she says, is to make residents sensitive to the kinds of psychosocial factors that contribute to disease. Though some patients' personal problems may seem intractable, especially if they are mired in poverty or suffering from profound emotional trauma, Trevino says, “Just listening can be incredibly healing.”
Collaborating with a psychotherapist is also beneficial. “You get better outcomes when physicians and therapists work in conjunction,” says Trevino. Proof is the almost 400 low-income, uninsured, or indigent patients so far treated at the experimental Family Support Service Clinic, which was created in 2000 with funds from the Texas Higher Education Coordinating Board. Under Trevino's direction, doctors at the clinic collaborate with psycotherapists to provide both mental and physical health care. Together, they encourage patients to take care of their health—whether that involves taking needed medication or ending an abusive relationship. Based on cases they've seen, Trevino believes that it's been an effective approach, with patients improving more rapidly and needing fewer doctor visits, and she says, “We're currently compiling the hard data to assess its value empirically.” The Family Support Service Clinic is housed at the Galveston County Coordinated Community Clinics (4Cs) at St. Mary's Clinic.
The collaborative model at the Family Support Service Clinic mirrors Trevino's own practice. In addition to her teaching, advising, and administrative duties, she sees patients about twelve hours a week. “I've always worked closely with physicians,” she says. “I wouldn't know how to behave if I went out on my own and didn't have that interaction.” The cumulative effect of having two professionals caring and recommending a course of treatment is “incredibly powerful,” she says. Furthermore, therapists such as herself are in a better position to report on patients' progress since they see them more often than the doctor. “We can send up a red flag,” she says.
Physician Alice Ann O'Donell, a professor in UTMB's Department of Family Medicine, has worked together with Trevino in providing patient care on many occasions. “She's really taught me the value of family therapy,” O'Donell says. “A lot of times when the patient's emotional hurt and pain go away, the physical pain follows.” Like many in her department, O'Donell says Trevino helps her as much as she helps her patients. “She's a wonderful listener who really helps you focus and figure out what you are capable of doing in a certain situation so you don't get bogged down and frustrated,” O'Donell says.
Indeed, Trevino has managed to help many in her department deal with professional as well as personal issues. Gosselink says, “With Dorothy, you end up talking about a lot of topics—a lot of issues about yourself that can get in the way when you're treating a patient.” Colleagues and students describe her as compassionate. “She never judges you,” says physician Catalina Triana, who now practices in her native Colombia but was a resident as well as a fellow in behavioral medicine in the Department of Family Medicine from 1997–2002. “Every time a resident was in trouble, they'd go to Dorothy's office because she is so perceptive and empathetic,” she says. Trevino taught Triana hypnosis in preparation for the delivery of her son two years ago. “The epidural anesthesia didn't work, but the hypnosis did,” Triana says.
Though most people describe Trevino as relentlessly upbeat, she acknowledges that it can be wearing to deal with despair day in and day out. “Sometimes you have to pull back and take a breather or you will definitely burn out,” she says. Her refuge is the water, particularly Offatt's Bayou, which her home overlooks and where she likes to kayak. “You have a lot of freedom in a kayak,” she says. “You can go out into deep water or wind around in the shallows where the water is just a finger deep.” She also escapes to Italy whenever she can. A watercolor print of the Duomo in Florence hangs in her office.
Trevino's next challenge is to find funding to continue her work at the Family Support Service Clinic, since the Texas Higher Education grant ran out in August. Specifically, she'd like to begin a study that will quantify the value of the collaborative health care model in treating diabetes. The disease now affects sixteen million Americans, with a million new cases diagnosed every year. “It's a huge public health problem that can be more effectively managed if psychosocial issues are addressed,” says Trevino. As with any illness, it's not so much mind over matter as “the mind matters.”
Kate Murphy writes regularly for The New York Times , Business Week , and other national periodicals.