Toward the end of office hours late one summer afternoon, I see Victoria in an exam room, leaning over a table wiping away tears. She appears disheveled and exhausted, like she has not slept or showered in a couple of days. When I ask what is upsetting her, she tells me that she’s had a stressful interaction with a family member. I say how sorry I am to hear this, and we sit in silence for a moment or two. Her sad, moist eyes look like floodgates keeping back a storm surge. Before entering the room, I glanced over the triage portion of her chart. In the place where my medical assistant records presenting complaints, it said simply, “personal matter.” Victoria’s conflict with her family is not incidental; it is the reason for the visit.

I have known Victoria for many years. Her diabetes and blood pressure are always poorly controlled, and she suffers from severe anxiety. She struggles to refill her prescriptions on time, and usually forgets to have her lab testing done. As I have learned about her life though, this is easier to understand. She is unemployed, and divorced from a husband who walked out ten years ago leaving her with two young boys to raise alone. It wasn’t long before her children discovered alcohol, marijuana, and opioids. “The police are regular houseguests,” she says.

Talking with Victoria about preventive care is challenging. Vaccines take some coaxing, but gynecologic care and colon cancer screening always manage to get postponed for one reason or another. We spend a lot of time talking about her financial struggles and issues with her sons. Perhaps those conversations led me to think I knew Victoria well as a person.

“Victoria, it’s all right. You can tell me what happened, and I will listen.” There was a recent family gathering, and someone reappeared after many years. She had hoped he was dead.

“I have never said anything about this before. I thought I had made it disappear from my mind,” she whispers.

From a cruel, dark place, Victoria tells me of her abuse between sobs, shuddering and voice cracking as if she is reliving it. It is a horror no young child should ever endure.

When I look at Victoria through a clearer lens, there are many clues—her anxiety, troubled marriage and family life, avoidance of physically intrusive examinations. I realize that I hardly know her at all. I focus on her health issues, and despite many stumbles, we have a nice rapport. I accept whatever she is willing to share about her tumultuous home life, but I do not ask how it all came to be so. Now I float with her in a reservoir of pain and shame.

Victoria always shows up for her appointments. I think this is one way in which she conveys her trust, and I wonder why I have never received this as an invitation to inquire more deeply about her troubled past. Now I imagine how terrifying some medical encounters may be for her, especially examinations and procedures which may recall her trauma. I might have attended to this with a simple inquiry like, “Have you experienced anything that makes seeing a doctor difficult or scary for you?” This powerful phrase has gathered dust from underuse.

My thoughts return to the moment. Words fail me, and I offer Victoria the landing of my presence as demons from her past try to pull her under the surface. I think of how many times in her life the landing was a mirage composed of hope, erased by her family’s cruelty or indifference. My own landing has begun to gain sustenance from empathy, and renewed awareness of the unseen wounds which many of my patients may bring with them. Louis Pasteur said famously, “In the fields of observation, chance favors only the prepared mind.” As I help Victoria out of the abyss, she prepares my mind and heart to be trauma informed [1].

I stay as her sobs and trembles diminish, but the suffering evident in her eyes remains. Sometimes building trust may not be enough. Creating safety is another step to establishing rapport which often gets left out, yet should be part of all patient encounters. This requires more than empathy; it begs for careful outreach into what may be a chasm of wounds. “Have you experienced anything that makes seeing a doctor difficult or scary for you?” It may take time for patients to find and summon their courage to disclose a trauma, and my task is to build a bridge which they can cross when ready. I imagine that just knowing the bridge is there can be reassuring.