By Stacey Kusterbeck
When Nicole McAmis, MD, started her OB/GYN rotation during her third year of medical school, an instructor asked her to give a presentation on human trafficking, since it was something missing in the curriculum that year. Many attendees admitted they lacked knowledge of the topic.
“I definitely felt that there was a need for this type of training, and wanted to understand why human trafficking is not widely covered in medical curriculum,” says McAmis, currently a resident at Stanford’s department of emergency medicine.
Motivated by the lack of training she received on human trafficking in medical school, McAmis wanted to know if the same was true for healthcare providers generally. McAmis and colleagues surveyed 6,603 providers.1 Only 42% said they had undergone any formal training in human trafficking. Ninety-three percent said they would benefit from such training.
“It is disheartening that the majority of healthcare providers have no knowledge of this important subject,” McAmis laments. “Ultimately, this means that they lack the knowledge and specific tools needed to assist victims.”
McAmis sees a need for mandatory training on human trafficking. She created a training program consisting of a PowerPoint presentation and a simulation program. Recently, McAmis used the program to train the ED residents. Currently, McAmis is studying how much training is necessary and how often it should be conducted. McAmis also created a Conversations Toolkit (part of the Emergency Medicine Residents’ Association MobilEM application) with a human trafficking section covering risk factors, tips to approach conversations, and screening questions.
Multiple other efforts are underway to improve the ability of healthcare workers to respond to human trafficking.2,3
“But there has been insufficient work examining EDs’ actual readiness to properly implement trafficking screening,” says Makini Chisolm-Straker, MD, MPH, an EP at Mount Sinai Health System who co-authored a paper on this topic.4
In Chisolm-Straker’s experience, ED providers often voice interest in screening patients for trafficking.
“But they need regular training on what screening actually means, and how to systematically and ethically do it,” Chisolm-Straker says.
Options include lectures, webinars, or workshops. Emergency clinicians need training on what trafficking is and to understand people of all genders and nationalities are affected.
ED providers “are in the perfect position” to help identify victims of human trafficking, McAmis says. “Greater than 88% of victims come into contact with the healthcare system. The majority will present to an emergency department,” she reports.5
If human trafficking is suspected, “it is important for ED providers to recognize that this is a situation that often requires dedicated time and attention, just like many of the other critical patients that we treat,” says Shannon Findlay, MD, MPH, assistant medical director of the department of emergency Medicine at the University of Iowa Hospital and Clinics.
EPs may need to involve social workers or community advocates who can help with difficult legal questions or safety concerns. Even if patients do not disclose their situation or accept resources, it is important to convey that the ED is a safe place to which they can return.
Researchers analyzed 23 studies on adult human sex trafficking. They found a lack of formal training programs and validated screening tools.6
“Screening for trafficking is something that is very much not standardized,” says Amy Caggiula, MD, one of the study authors and an assistant professor of emergency medicine at the George Washington University School of Medicine.
Not many EDs have established protocols, and even fewer of those protocols have been validated. Researchers were looking for a screening tool for the ED that was quick and effective.
“Unfortunately, we didn’t really find one that was applicable to our setting and patient population, which was disappointing,” Caggiula reports.
Despite the lack of good screening tools and training, EPs must maintain a high level of suspicion for human trafficking and be aware of their reporting obligations. Federal law does not mandate healthcare providers to report suspected human trafficking of patients age 18 years and older.7 “However, there are various laws that could require an EP to report human trafficking,” says Chadd Kraus, DO, DrPH, FACEP, system director of emergency medicine research and an attending EP at Geisinger Medical Center.
Those include mandatory reporting requirements for child abuse, domestic violence, and elder abuse. “Reporting requirements differ by state and are often part of the mandatory reporter guidelines,” Kraus notes.
EPs should be aware of local and regulatory requirements. “In addition, emergency physicians have an ethical and professional obligation to notify the appropriate authorities of cases of suspected human trafficking,” Kraus says.
ED policies on how to address human trafficking can outline all these obligations for EPs. EDs could base such policies on the American College of Emergency Physicians (ACEP) human trafficking policy. The ACEP policy stresses the need to address the “medical, psychological, safety, and legal needs of the victims of human trafficking.”8
“Emergency physicians should have a low threshold for reporting cases of suspected human trafficking,” Kraus advises.
Kraus says EPs should objectively document the circumstances that raise suspicion of human trafficking, how and from whom that information was obtained, what steps were taken to assist the potential victim, and that the concern was reported to appropriate agencies, (including but not limited to law enforcement). “Cases of undetected or unaddressed human trafficking can result in harm or even death for the victim,” Kraus warns.
Considering the high stakes involved in these cases, EPs may wonder about malpractice implications. A patient or family could sue the EP for failing to identify human trafficking, but would be unlikely to prevail, according to Peter McCool, MD, JD, an attorney at Washington, DC-based Stein Mitchell Beato & Missner. “A negligence case would likely fail if brought. It would be very difficult to successfully prove,” McCool says.
To prevail, the plaintiff would need to prove each element of negligence. The first element is proving a patient/physician relationship existed. This would be easy to prove if the victim was a patient in the ED.
The plaintiff also would have to prove the EP breached that duty. To do that, expert witnesses from the same field of medicine testify as to what a competent EP would have done under similar circumstances.
“It is very unlikely that any emergency expert could establish a standard of care for identifying victims of human trafficking,” McCool says.
If the EP competently addressed the patient’s complaint and there were few, if any, red flags, it would be a hard to argue any standard of care was breached. The plaintiff also would have to prove causation, that the EP’s failure to identify a victim of human trafficking caused the injuries claimed.
“This means that but for the physician’s failure to identify a victim of human trafficking, the victim would not have suffered any injury,” McCool explains.
In other words, the injury in a lawsuit must have been caused by substandard care in the ED, not some other cause. Additionally, the plaintiff must prove quantifiable damages that resulted from the alleged substandard medical care. “In these terrible cases, there are unfortunately plenty of damages. But they arose out of the trafficking, and not the substandard medical care,” McCool says.
REFERENCES
1. McAmis NE, Mirabella AC, McCarthy EM, et al. Assessing healthcare provider knowledge of human trafficking. PLoS One 2022;17:e0264338.
2. Lee H, Geynisman-Tan J, Hofer S, et al. The impact of human trafficking training on healthcare professionals’ knowledge and attitudes. J Med Educ Curric Dev 2021;8:23821205211016523.
3. National Human Trafficking Training and Technical Assistance Center. Core Competencies for Human Trafficking Response in Health Care and Behavioral Health Systems. February 2021.
4. Smirnoff M, Potterbusch K, Clesca C, Chisolm-Straker M. Screening for human trafficking in one emergency department: Social acceptance and practical dissonance. Acad Emerg Med 2022;29:234-237.
5. Lederer LJ, Wetzel CA. The health consequences of sex trafficking and their implications for identifying victims in healthcare facilities. Ann Health Law 2014;23:61-91.
6. Marcinkowski B, Caggiula A, Tran BN, et al. Sex trafficking screening and intervention in the emergency department: A scoping review. J Am Coll Emerg Physicians Open 2022;3:e12638.
7. Jones Day. Human Trafficking and Health Care Providers: Legal Requirements for Reporting and Education. July 2021.
8. American College of Emergency Physicians. Human trafficking. Revised February 2020.
Multiple efforts are underway to improve the ability of healthcare workers to respond to human trafficking. But there has been insufficient work regarding ED readiness and properly screening for trafficking.
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