The “Patel Pause”: building capacity for trust after trauma

A brief, simple protocol of granting and withdrawing consent can help restore patient trust after medical or other trauma. An increased sense of safety and agency in your practice will help traumatized patients return instead of postponing care.

The Patel Pause is a pre-procedure protocol initiated in 2021 by pain specialist Hersh Patel MD, MBA, in collaboration with a patient who suffers from severe Complex PTSD from Developmental Trauma exacerbated by multiple medical traumas. Due to inhibitions caused by multiple lifelong traumas starting at an early age, the patient was unable to speak up when a procedure hurt. “I froze instead of telling him I would like the topical…I did what I was trained, hold still, shut up, and take it,” the patient noted in retrospect.

The trauma survivor explained the situation and asked Dr. Patel if he would help them work through it at their next appointment. They wanted to practice saying “stop” when they were in pain and to learn to feel it is OK to take a time-out and ask for the topical.

Dr. Patel liked the idea and further developed it. The day of the procedure he asked the patient if they would like “a trial run,” during which he would stimulate the injection site by pressing the capped needle against it. “Let me know when it’s painful and you want me to stop,” he advised. The patient quickly sensed that her pain specialist was never going to put enough pressure on the needle cap to make it actually hurt. This felt very supportive. The patient realized it was better because they could just say ‘stop’ for any reason, not only if it hurt. The two practiced the nascent protocol three times. “Each time it became easier. I felt more safe saying ‘stop,’” the patient enthused. “It felt empowering to have that happen, especially after non-consensual surgery robbed me of my sense of agency,” they said.

Dr. Patel decided to make this protocol part of his practice. He gave the patient the opportunity to name it. They decided it should be called the Patel Pause to honor the kind doctor who thoughtfully invented it. “Cognitively, I know I have agency with him, but my nervous system has not yet forgotten the abusive doctors who caused such deep harm I can barely make it through a routine visit. Every little reinforcement of agency helps. Dr. Patel’s being so kind to do this with me just took a few minutes of his time and actual care and consideration about what the patient needs,” the trauma survivor noted.

Having found the Patel Pause helpful before a procedure, the patient decided to ask their physical therapist to practice it before each dry needling of the lumbar region. With physical therapy three times a week the patient quickly realized their tendency to bark out the word “stop.” They decided to experiment with saying it more softly. This brought even more value to the pre-procedure protocol. “I just whispered it, ‘stop,’ and he stopped,” the patient enthused. “My nervous system was thrilled. It’s powerful to whisper and discover a man hears me, respects my boundary, and stops,” said the patient.

The steady repetitions of the Patel Pause during months of lumbar PT helped the patient’s nervous system prepare for a lumbar sympathetic block. To the patient, this was a new procedure in an unfamiliar section of the same hospital where the trauma occurred. They believe the advanced practice made the procedure easier and the environment feel safer.

The Patel Pause helps build a patient’s sense of agency through consent and withdrawal of consent. The patient determines when and for how long the provider may engage physically. That’s a very basic kind of agency, which the medical system greatly overlooks. This can disempower patients and make them feel like objects. “Consistent use with my PT has widened my window of tolerance for touch and helped my nervous system regain a new level of safety in a system that has been chronically fraught with danger for me. I now ask all my hands-on providers to utilize the protocol before they touch me,” said the patient.

With the Patel Pause patient agency is reinforced even when previously established with a familiar provider. “The more I explore the Patel Pause the greater my understanding of the deep need for a sense of agency in medicine, a realm where a patient’s agency is often bypassed in favor of expediency, familiarity, or certainty,” said the patient. “We need a lot more curiosity from our providers,” they asserted.

How to Perform the Patel Pause:

A patient’s sense of agency is centered on their feeling they have choices. It’s important to introduce the concept as an option, an offering.

You might note that you’ve come across this pre-procedure protocol that some people find helps them feel more comfortable during the procedure. You could tell the patient, “it’s kind of like a practice run to help your body and nervous system get familiar with what we’re going to do here. Some patients find that helps them feel more comfortable.”

Come to an agreement with the patient about what touching will be involved. You can use the below example as a starting point.

Tell the patient you’re going to make contact when they say it’s okay and you’ll stop when they say “stop” for whatever reason. Let them know it’s suggested to do this three times, but it’s up to the patient. And you can stop doing the whole thing at any time they say stop. “I’ll stop even if you whisper” can be very assuring.

The patient may also wish to see equipment and have it explained. That can help them orient in the environment, which may help them feel safer.

Explain the procedure and let them know it’s an option. If they accept, begin the procedure and talk through it.

Initial consent. The patient tells the provider okay or otherwise indicates they are ready to begin and be touched.
The provider touches the patient in the agreed-upon manner. When the patient feels inclined, they tell the provider “Stop.” Provider stops.
The provider asks the patient if they would like to do it again. If so, repeat steps 1 and 2. After the third “stop,” if the patient is ready, resume the touch and begin the procedure.

The most important aspect of the Patel Pause is the initial consent, withdrawal of consent, and giving of consent again. That pattern repeated over time can help build patient agency, which is essential for the sense of safety.

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