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Mary Coughlin: . [00:00:00]
I am so wicked excited to have Dr. Heather Forkey on our podcast today. And I thought we would just dive right in and invite you, to just share a little bit about your story. How did you evolve in your, life and in your medical studies to arrive at your current role,
Heather Forkey: well, Mary, thanks so much for having me with you. It's a delight to talk with you today. So I thought I wanted to be an oncologist and I went to residency in the late 90s to a place where I could do pediatric oncology. And, Accidentally, I was staying for an extra year as a chief resident and residents asked questions about kids in foster care and we started to gather information from the community, finding that. Interestingly, there were not a lot of straightforward answers, things were not pretty clear. And I got so interested in that that I said, well, let me put off that oncology career and I would stay and do primary care.
The hospital said, you know, the most about foster care could I take those patients? And I thought, well, [00:01:00] that's. Kind of silly that I would know the most the limited information I had but it was really a fascinating and wonderful group of people to be working with. And, the more I did it, the more I was intrigued by what their needs were.
Interestingly, this was sort of the mid to late 90s and we. Hadn't yet really understood trauma and I had a number of conversations with colleagues saying, there's something so common to these kids that it feels like we're missing something really significant and over time, I moved to Massachusetts and continued to see kids in foster care, as this information about trauma began to become more widespread and as soon as I heard about it, as soon as I read the adverse childhood experience studies, I knew that that's what we were looking at and and that's what hooked me in this sort of journey is that I thought, wow, if, if I didn't know about this, I'm sure my, my colleagues don't know about this and I'm sure my Kind of became really[00:02:00] on fire about trying to know more about what was going on, trying to disseminate what we could know and, and sort of push the boundaries so that we could serve these kids better.
And as a result, I think we serve all kids a little bit better if we understand trauma because. Although kids in foster care, who is the primary part of my job, I'm a pediatrician that runs a program for kids in foster care. They're not the only ones who experience trauma. There's the, probably some of the worst of the relational health trauma that there are, but I think as we've come to understand, it's pretty universal issue.
So that's how I wound up here, just really fascinated and curious about what was going on for my patients. And
Mary Coughlin: it sounds very pioneering to be honest with you particularly, when you were saying, oh, gee whiz, you got a little bit curious in that chief resident position and then even the surprise when you were just sharing it right now, when you're retelling the tale about I'm the one that knows the most about [00:03:00] this, you know and I think it just kind of goes to show, Really the evolution that, all of health care is is continuously uncovering and discovering new aspects, deeper components to what it is to optimize the health and wellness of those that we've been called to serve.
Heather Forkey: Absolutely. Yeah. I think what's sort of fascinating is that when I was in medical school, I really thought to myself, wow, you know, we've figured it out. We've discovered what there is to be discovered. And, you know, now we just have to put it into practice and kind of really living that sort of evolution of medicine myself.
It's been. It's been an enormously joyful journey.
Mary Coughlin: Yeah, yeah, I, I totally get that. I, I feel a little bit similar, in that evolution and discovery piece, because I think once you graduate, you kind of like, slip into that, that job mode, you think, okay, this is it, I mean, there's a few new meds and stuff like that, that pop up, but we basically know everything we ever needed to know about.[00:04:00]
The human being and what the human being needs. And it's like, Oh, yeah, no, put the brakes on. Nothing could be further from the truth. But I think also the cool thing about what you just shared is that you've maintained that level of curiosity that you continue to explore and and uncover other components of where are the gaps then in, in meeting the needs of this population.
And is there another layer, and that just kind of is a continuous, it seems to me at least, like a continuous piece of who you are and, and, and the work that you do, I mean, particularly, with this role with the American Academy of Pediatrics, right? do you find that that's an opportunity for you to continuously pioneer this and uncover more and share that, right?
I mean, it's one thing to to uncover something. It's a whole other kettle of fish to then disseminate your discoveries in ways that are, acknowledged, [00:05:00] received,
Heather Forkey: Yeah. I mean, I think that that's sort of the, the, the way that you kind of stay fresh and you stay interested because, what trauma teaches us is that we We are creatures that need each other and that it is in those interactions with my colleagues that I am challenged.
I have the opportunity to sort of have that. You know, as we talk about the affiliate response, that tending and befriending that ability to sort of take something we don't know, take something that. Frightens and frustrates us all and to address it as a group, and I'm continuously amazed that every time I am with a group of people who love this topic or thinks about this topic, they bring up some aspect of it that, we don't really understand yet, or we haven't thought about the way we need to think about it.
And it'll take me down another
So it really is this sort of ever evolving process [00:06:00] in those relationships with my colleagues and with, and with our patients and foster parents who also ask those challenging questions. there's no resting. There's no sort of saying, okay, we got it now. It really is sort of constantly, you know, can we do this better?
Why didn't we ever think about it this way?
Mary Coughlin: Well, I think You're just kind of highlighting, my next question with you how has your journey expanded or impacted your understanding of the importance of trauma and the trauma informed perspective.
but there's a caution there that you don't want it to become this, next big thing that just kind of flies by and nobody really unbundles it, unpackages it.
It becomes that buzzword that do you really know what this is all about? Do you, are you really understanding it? You know, am I capturing that pretty on point
Heather Forkey: or? Yeah, I, I mean, I think what you're, what you're reflecting is what is trauma and what it is, what is it not? What is resilience and what is [00:07:00] it not?
And I think, One of the phenomenal experiences is that we have been able to put on, you know, through that analogy of putting on your trauma lens and look at what we've always looked at with a new lens, right? That's what we used to think of, in particular, in the population of patients that I serve.
Was either willfulness behavior or multiple psychiatric diagnoses makes entire sense when you put on sort of the trauma lens and say, okay, with this sort of exposure where the natural kind of consequence of that is what we're seeing. And that gives you a new way to discuss it, a new way to approach it, a new way to treat it.
I think what you're reflecting is the danger of sort of that aha, right, that people want to have an answer for everything. And this answer has really satisfied a big piece of things we had a question about, but it isn't the answer for all, people often come to me and say, well, is this trauma or is that [00:08:00] trauma?
And similarly, I think that there is another concern that we say that we overuse trauma and we undervalue where people can grow. Right. So there's sort of one issue where people sort of say, well, is that trauma? Is this trauma? Yeah, probably not. You know that what we're talking about is something that's so significant that it alters physiology.
Alternatively, sometimes I think what I'm hearing now is people saying, well, this is a person who's experienced trauma. So we, can't expect anything from them. And I find that is what concerns me a lot these days I think what, what I have appreciated is the value of positive relationships, the number of people who are It demonstrates so much resilience.
there's a big push to get a sports for everybody. the ACE score was designed to be a research [00:09:00] tool.
It had enormous value in us understanding that in populations, this had an effect, but the kind of bumper sticker, I would say is, it's not about summing the suffering. It's about building the buffering and saying. You're not the sum total of the bad things that have happened to you. You are, a beautifully resilient human being, but we might need to think about how we support that resilience.
And I think that those are the 2 areas where I feel like there's some cautions on either
Mary Coughlin: end. Yeah, I love how you articulated that and I, my, I'm wrecking my brain right now because it was a really cool paper that actually talked about those unintended consequences with now recognizing, the impact of trauma and, this, this paradigm of trauma informed care but again, trying to boil something down to a simple explanation when we're talking about the complexity of, the existence and the lived [00:10:00] experience of a human being. We got to get that out of my head. That is completely impossible. And in this paper, they did talk about exactly what you articulated, that labeling piece, you know, like, Oh, well, you got a score of nine good luck.
you're probably not going to be very successful. I mean, a holy macaroni, talk about undermining somebody's full potential. So, I do love that. phrasing summing the suffering versus building the buffering. I mean, that says it all right there that yes, bad things can happen, but everyone is greater than the sum of those experiences.
And, and so to really help folks embrace that help folks understand that can be challenging because it can be wicked easy to just go, Oh yeah they've got this, that, and the other. You know, they've got this horrendous trauma history, so this is probably as good as it's going to get. You know, says you,
Heather Forkey: but, and there's a fine line, I think, between [00:11:00] validating, you know, it is so important.
I think one of the things we have learned from trauma informed care is how critically important it is to be seen and heard by another human, like to have your experience heard. Validated and acknowledged, one of the worries about sort of some of the screening that's done, you know, fill this form out and I'll never talk to you about it is that you can feel even more invisible in that, in that experience, but I think There's this duality, right?
We need to, know that people hear us and care and, and appreciate what we've been through. And that's a moment for pivoting. That's a moment to say, and where do we go from here? And if we forget to, to take on the second part, I think we undermine the value of what we know.
Mary Coughlin: Yeah, and I think we traumatize them even more.
We make them, the individuals feel even more lost and alone and, and isolated. And again, I, I absolutely cannot believe that that's anyone's intention, but that's, when we [00:12:00] disconnect with the fact that. This person isn't just your next patient. This is a living, breathing, fellow human being.
And oh, this just jumped into my head. It's kind of like reconnecting our awareness with that idea of Dan Siegel calls it this intra connection. And he talks about I'm a me, but I'm also We and, and we need to not forget that, and you talk a lot about that, with the relationship piece of it and how crucial that is to to everything, even in the face of talking about healthcare, diagnoses that may be, terminal or life limiting that, you don't just it's very difficult.
You know, walk away, you know, that that relationship can really transform how that individual then accepts that situation and moves on and lives to their highest potential in spite of, that situation, but we have to help folks, healthcare professionals, and I think [00:13:00] human service folks to folks that are repeatedly exposed to that raw edge of that situation.
Of humanity that are repeatedly immersed in suffering, bearing witness to suffering, how that can erode their capacity for fostering healthy relationships or or supportive relationships. Do you find that in in the work that you
Heather Forkey: do? I think absolutely. one of the things that I have found truly fascinating about the work is Really appreciating that the human infant is born really underdeveloped compared to any other species.
Thus, there is this enormous hormonal and neurologic and the parts of our system which are designed to link us to other humans who will take us through that process, right? That link, that bio behavioral synchrony allows us to develop as humans in the beginning, [00:14:00] but is our lifeline throughout life, right?
And that critical nature of bio behavioral synchrony. Is something that I'm, I'm, I'm interested to see how. How that moves through society. One of, one of the challenges I think of our time is the distress of isolation that, even on social media, it becomes more isolating. It becomes more, narrowing in focus.
we are built for this synchrony. We're built to sort of look at another human and sort of compare ourselves and bring ourselves to that level. If we think about the effects of social media where we're Constantly comparing, but to everybody's best day or to, a curated version of others.
We're, we're, we're messing with physiology in a way that is, is not how we're built, that we are built to live in communities of 15 or so, you know, like that there's, there's a physiology that if we [00:15:00] understand, we really have a lot of the tools for resilience. And if we. Don't pay attention to that physiology.
We do so at our peril. And for the patients who are the most in extremist, their need for that synchrony is so profound that for those who are working on that edge, it can be exhausting because it requires. Such a giving himself to do the work. It is. What is biologically embedded? So if you're going to think with someone who's in distress and sort of put their mind in your mind and be the emotional container that comes at a cost and you need the other people around you to sort of balance that.
So it is. It's a it's. To understand trauma and resilience really opens up a whole new way to understand health
Mary Coughlin: care. Yeah. Yeah. you could say that it's foundational. I think it's really one of those core competencies that health care professionals [00:16:00] really need to be able to step up to the plate and do the job.
at their highest level because it is so multi dimensional, There's just so much more to it. And when we don't acknowledge that we do add more harm. And, you know, I mean, just thinking about first, you know, harm.
Heather Forkey: Yeah, I think. You know, in medicine, you can never address what you never consider, right? and I think trauma is really kind of a universal precaution topic, right? We, we need to walk into every encounter that we have with families and with patients with the understanding that you don't come to a health care setting most of the time when everything's just dory.
And even if you do. There are probably some things that are impacting your health that you may not even be aware are impacting your health. So that, basic understanding of, the role of trauma and resilience, the role of that physiology is sort of [00:17:00] something we're trying to introduce to residents and, medical students as well, so that early on in our training, We can have that lens, that we can look at all the other diagnoses, all the other things that we do, and sort of think about it from that trauma perspective, from that concept, it's not about what's wrong with you, it's about what happened to you, and from the concept that it's about that buffering.
How do I do my work so that I make your resilience higher and the effect of trauma lower?
Mary Coughlin: Yeah, it's I don't know who coined this evolution of that. It's not what's wrong with you, it's what happened to you and what's strong with you. And I like that because that's, that's our opportunity, right? so from a NICU perspective, you know, I'm talking to a family.
I know this is catastrophic. I know this is overwhelming. This is. It's frightening. We can't change that reality. So let's figure out how we're going to navigate this and I'm going to walk alongside you and you know, what are the things that we can put in [00:18:00] place to support that resilience and and also help folks realize.
This ain't no straight line. You know, you may be feeling really good today. You may not be feeling so great tomorrow. And, and that's the other piece, right? That we as healthcare professionals need to understand is that it's going to be this bumpy ride. I would imagine it's, it's wicked bumpy in the world of, of health care for foster children and children experiencing adoption and, and families and the, and the caregivers around that experience is, is that fair to say
Heather Forkey: Yeah, absolutely. I mean, I, I I would add on to what you just mentioned, that it's not about what's wrong with you. It's what happened to you and what's wrong with you. And in medicine, trauma is my job. I think that there has for a long time been, okay, trauma happens, but that's not something a doctor would take care of or a nurse would take care of.
That's not a healthcare problem. And I think one of the interesting pieces is [00:19:00] we've really come to understand, you people say, well, trauma is one of the social determinants of health. And I think they are somewhat different, but I would suggest changing the phrase again and saying social determines health.
Right. Who you have around you, how you are supported, what does the social situation that you're in that will determine your health. And so, yes, determinants in, you know, homelessness or poverty or food insecurity, critically important. Absolutely. But I think. They are not the direct relationship, they can have a direct relationship on social connections, but it is the social connection that is what buffers or doesn't buffer what goes on in your life.
And so, for getting back to your question, how does this impact kids who are in foster care families who are going through adoption? It's huge, right? I mean, creating those relationships, dealing with the relationships from before, managing [00:20:00] these, the way you walk forward with those kind of histories, it becomes critically important to understand for health.
Mary Coughlin: Yeah, it has to be. So given all of your experiences and your passion are there some priorities that you feel that as healthcare professionals or as a healthcare system, and maybe a human service system as well, that we need to address in order to really better serve these children and their families living in trauma.
Or living with trauma.
Heather Forkey: I mean, I think they are the things that we have already talked about, but making it clear, that idea that, trauma informed care has become a bit of a buzzword. And I'm sort of, I'm waiting for the day. I go into Starbucks and they say, we're a trauma informed coffee, you know, like, what does it really mean for, for people to be trauma informed? There's no one definition. So there's a vagueness to it. And I think it starts with the science. It starts with [00:21:00] understanding what is the physiology of what's happening here for those of us in medicine in particular, that we have to appreciate that this is a medical issue and we cannot do our jobs unless we fundamentally understand this as a physiologic issue.
Yeah, then the next issue becomes how we operationalize that in ways that are meaningful and not just window dressing because if you just say, you know, we're going to dress up the waiting room and now we're trauma informed. Yeah, I have no problem with dressing up the waiting room, but. If how I interact and the resources I have for my patients and the way I address their needs doesn't change, then I'm not really doing that.
And so, I think that those are sort of the, the, the critical issues right now is how do we take this enthusiasm and momentum for trauma informed care and make sure that it continues to be something of substance and not something that really is just sort of this, you know, whitewashed. [00:22:00] Yeah. You know, business
as
Mary Coughlin: usual.
Yeah. I mean, that's one of the challenges that I really I mean, I, I struggle a little bit with it, so we've got this certificate program. We're trying to help people reconnect with the awareness of the human aspects of who they are and how they show up to the work that they do that, yeah.
I really do believe that how you show up as a human being is, is the turnkey. The skills, like whether you're a nurse or a physician or a therapist or, you know, like all of the things, those are your, that's your toolkit. That's how you act out the who that you are. But what I run into, right, and I'm not saying I have this perfect by any stretch of the imagination, but the thing that I run up against is like, well, how do you measure that?
How do you how do you really demonstrate that that makes a difference? That this person that now feels more empowered and feels more courageous about their vulnerability as a vehicle to [00:23:00] connect with the suffering of another person, how do you measure that, you know? And I, I don't know, I kind of like, when I start to hear the word measure now and Trust me, I really do respect and admire science and all that kind of stuff, but it's like, ugh.
This again, come on. I mean, there is some things that are not necessarily quantifiable, but certainly can be qualified based on experience and, Do you do you struggle at all with that kind of a,
Heather Forkey: Yeah, for those of us in medicine, you know, we need to be sure what we're doing works and it's part of do no harm, right?
So, I think we do need to find better ways to measure it, but I think the problem is that. Doing this work isn't going to be measured 10 minutes later or two days later, right? The effect of what we do is unlikely to sort of fit some of the traditional models of what, you know, the way if I give a medication, I [00:24:00] can measure in a month, whether it's had an effect.
I think some of the problem for us is that what we're looking at is, does this have a longer term effect? That these are probably not things that are going to be immediately measurable. In the same way, in terms of outcomes. Yeah, I mean, a study looked at what happened in childhood and health outcomes in adulthood.
Right? The benefit of that study is that it did give you some of this longitudinal information. I think, as we do this work, we're going to have to ask the question for people that we interact with, can we measure the effect of promoting positive experiences in childhood, and how does that impact outcomes, overall, at the individual level and at the population level, so that we get the data that's correct, right?
I don't think that we don't want data, but I think we need to think about what is the data that's going to be meaningful in this topic. And, similarly, there have been studies that have sort of said, well, a screening is [00:25:00] acceptable and, feasible in a clinical situation.
Oh, that's great. But does it do anything? Does it help you? I think overestimate the value of something that that is being done. And I think we don't have yet. Sort of the construct of the ability to measure kind of some of these long term outcomes, which are probably more of what we're going to where the benefits are.
Yeah,
Mary Coughlin: and I, I like that you highlighted that situation. I haven't kept completely abreast of the. Evolution of this ace testing proposal. I don't know if that's the right word. That seems to be kind of moving east. But again, It seems like when you're collecting information You have to really examine how is that helping you help that person, you know, if it's helping you label them and maybe not the best information to gather and stuff.
And certainly all the dimensions of retraumatization too, when, when we do those [00:26:00] things and, and not, you know, this just popped in my head. So I just feel like I have to say it, you know, sometimes I think we have so much. Hubris around who we are as health care professionals that just because I'm wearing a white coat and I got a stethoscope around my neck means that I deserve to hear your story.
and, and this is the first time you're meeting me. I don't think so. and we see that all the time, right? I see that all the time in clinical practice. I'll ask, a mom. So how you doing? And what did they say? Cause they feel like it's just a greeting. I'm fine. And, and I feel good because you said, fine, that makes me feel good.
I don't have to do anything else. And I move on my merry way. But now kind of looking back, I'm thinking, how could you possibly be fine? But I didn't foster that relationship again. It comes right back to that pivotal piece of the responsibility I have to help you feel safe.
And feel like you can trust me. I really am authentically here to help you in all the [00:27:00] ways that I can,
Heather Forkey: I think what you're hitting on is something that really healthcare is stumbling on significantly now, you know, that there's the, the concept is that it's a fancy term is epistemic trust, which is the idea is I, I cannot learn from you, take knowledge from you or benefit from our relationships unless I believe that you have my.
Best interests at heart that you are looking at the world from my perspective And medicine has stumbled because we have said to people just do it. Or we know better You just do what we tell you and people are saying so I don't trust you I won't because you don't look at the world with my perspective in mind.
You don't listen to what I have Okay. And I think exactly what you bring up is a big challenge for us. That's the fundamental to trauma informed care. Is really recognizing that my job first is to hear my [00:28:00] patients and to try to look at the world with their perspective in mind. How are they living this and only once they appreciate, you know, I can sort of feel like I've done a good job with that, but until they believe that we, we, we're not going to get anywhere.
So I think I think what you're hitting on is one of the most profound issues for healthcare
Mary Coughlin: today. Yeah, I mean, I have not figured out the solution yet. I mean, I definitely think it's a process that it's a skill. I think there's a skill in that for sure. Right. And that we can help people cultivate that skill of, of active listening, being open hearted, fostering a connection of trust that transcends my role or my position of power, that, that that Actually can undermine my ability to make an authentic connection with you.
If I'm not aware of that, right, you know, kind of like putting down the putting down the shield, putting down the God and just being [00:29:00] me and saying, look, I'm here to help and really fostering that relationship. So the name of the podcast is care out loud. And I won't torture you with the backstory on how I came across that name.
But In all honesty, I mean, Heather, you really exemplify, at least to me, what it means to care out loud and I felt so honored and, really grateful to have made your acquaintance and to be able to just like, you know, drop an email and have you respond so quickly and, and have this shared passion with you.
So. All that being said, I would love to hear your perspective, then, on what does it mean for you or maybe what does it look like, both are cool to care out loud.
Heather Forkey: You know, I, I think, to me, it comes back to my early experience with the patients that I have been working with who are in foster care, is that when we can name What is going on and validate [00:30:00] that it is profoundly powerful to say your response to this event is entirely how humans are built to respond.
This is not something wrong with you. This is something entirely right with you. There's a quote that I. That is attributed to Mr. Rogers, which is anything that is human is mentionable and anything that is mentionable is manageable, but we need to say it out loud. Like, we need to say it out loud and I, I'm constantly amazed that that well intentioned people often feel like, well, I shouldn't say anything.
I shouldn't call this out. And of course, there's no reason to sort of be in someone's face or, but I think there is a huge value. And I'm saying, I am so honored that you would share that with me. I can appreciate how this has had a profound impact on your health. As I look at these symptoms, given that, which has happened, [00:31:00] they make perfect sense.
I think as humans, we have always known that trauma has effects, right? But we are now able to say, we are able to articulate that, and it is now our job to do that. Yeah. And I think that that's powerful.
Mary Coughlin: Yeah. And there is an element of psychology understanding human psyche that transcends It's all the work that we do in healthcare and when we don't acknowledge that dimension, we reduce these beautiful human beings to an object.
we went into this work to serve and help folks heal and, and, and. Be well and live well So Oh my gosh. You're just such a rock star before I let you go.
Before I let you
Heather Forkey: go. Mary, your work is amazing. And I'm so delighted to hear that you're going to bring your comments back and Perpetuate all this great work that you're doing. God bless
Mary Coughlin: you. Thank you so much. So, but as we kind of close up, I would love [00:32:00] for you and this might feel heavy. Okay, so you can take a breath.
But what is one negative wisdom or insight that you've gained over your career that you would just love to share with the world right now?
Heather Forkey: I don't know that I can boil it down to one thing. I, you know, people often say to me, what do you go to? This may not seem like much, but whenever I'm interacting with people professionally, personally, in all sorts of situations, and it's, and it's going sideways. I think to myself, where is the lack of safety? What, is making me or this other person feel unsafe? Because that's when we go sideways and that fundamental concept that we are here to make each other feel safe.
And when those interactions have led 1 or the other of us to not feel safe. That's when we're having trouble and and I think that that that's [00:33:00] afforded me a number of opportunities to sort of say, okay, let's let's pause here for a minute. And and again, and maybe sometimes say out loud, you know, there's something that we're not getting at or there's something that I'm overlooking or there's something that's happened or maybe we all know exactly what it is.
And we just have to sort of get to a place where. We can talk about it. So I don't know that that's the wisdom you're looking for. But I will say, I think that this work in trauma has really given me a enormous appreciation for how critical safety is in every moment of our lives and every interaction.
Mary Coughlin: That's perfect. That's exactly what I was looking for. Exactly. And I think, we take it for granted, we don't really appreciate how quintessential it is for our relationships with everybody, not just our patients, right? But with our family, with the guy down at the dry cleaners, with all of our interactions with people.
So [00:34:00] thank you so very much, Heather.
Heather Forkey: It's always lovely with you. So thank you so much for. For this great opportunity.
Mary Coughlin: Oh, you're an amazing human being. Thank you so very much.
