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DIAGNOSIS AND TREATMENT
Violence in Intimate Relationships and the Practicing Internist
New “Disease” or New Agenda?
15 November 1995 | Volume 123 Issue 10 | Pages
774-781
Domestic violence is endemic in U.S. society and is seen
in nearly every venue of medical care. A history of abuse should
be considered and routinely queried in all women who present
for emergency care, should be suspected in any woman who presents
with an injury, and should be routinely screened for in primary
care settings.
Clinical
manifestations, suggested diagnostic strategies, obstacles to leaving
the abusive relationship, and the barriers that patients face in
obtaining and that physicians face in providing optimal care in
situations of domestic violence are discussed. Physicians can play a
pivotal role in primary prevention, early intervention, and follow-up
care during and after an episode of intimate partner violence.
Clinical competence in the treatment and prevention of family
violence is an important component of the new agenda for health care,
particularly in generalist fields such as general internal
medicine.
Ann Intern Med. 1995;123:774-781.
Core competence in screening, recognizing, and treating the short-
and long-term manifestations of violence in intimate relationships is
increasingly expected as the standard of care for internists and
other generalist and specialist physicians. Yet, most practicing
physicians have received no education or training in this area during
medical school, residency training, or continuing education [1-4].
The objectives of this paper are the following: 1) to help physicians
better recognize and understand the spectrum of clinical
manifestations of intimate partner violence; 2) to introduce and
reinforce the concept of routine periodic inquiry regarding current,
past, or potential victimization as a component of standard
patient care in generalist and subspecialist practice; 3) to
discuss the range of difficulties that battered women face in
leaving abusive relationships and in accessing and interacting
with the health care system; 4) to discuss the logistic and
attitudinal barriers that physicians face when confronting issues of
violence and abuse in their practice settings; 5) to summarize for
practicing physicians the skills that can be used in the care of
patients who may be at risk for or suffering the effects of
intimate partner violence; and 6) to enable physicians to gain a
new understanding of violence in the context of the life cycle
of the patient as a member of a family and community and of the
medical, social, and cultural contexts of violence as learned
behavior in our society.
| Background and Definitions
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|---|
Relationship
violence can be defined as intentional violent or controlling
behavior in the context of an intimate relationship [5].
Although most victims of domestic violence are women in heterosexual
relationships [6],
the incidence and prevalence of domestic violence appear to be
similar in male and female homosexual relationships [7,8].
This finding underscores the predominant constructs of power and
control in this syndrome as opposed to gender. Thus, violence
throughout the human life cycle, expressed as child abuse and
neglect, dating violence, domestic violence, elder abuse, and abuse
of the disabled can be viewed as learned behavior manifested to
assert power and maintain control.
Domestic violence encompasses not only physical injury but also
threats, sexual abuse, emotional and psychological torment,
economic control, and progressive social isolation [9].
In fact, physical violence usually occurs in the setting of a
prodrome of nonassaultive behaviors, which can occur in any
combination over a varying time course.
Risk Factors and Clinical
Characteristics
It is widely acknowledged that domestic violence is prevalent in
all racial, educational, geographic, and socioeconomic segments of
society. Various clinical and demographic characteristics of women
who are currently being physically abused have been elucidated in the
study by McCauley and colleagues in this issue of Annals [10].
In addition to acute physical trauma, domestic violence is associated
with many physical and psychological sequelae, including multiple
somatic symptoms [11];
chronic abdominal pain [12];
chronic headaches [13];
pelvic pain [14,15];
and anxiety, depression, post-traumatic stress syndromes, and
other psychiatric disorders [16].
Alcohol and drug addiction, musculoskeletal symptoms, and eating
disorders are other health-related sequelae of short- and long-term
abuse [17].
Physical violence seems to be particularly common during pregnancy,
with prevalence estimates ranging from 16% to 37% [18-20].
Obstacles to Leaving an Abusive
Relationship
Many battered women endure a pattern of progressively escalating
violence over months to years but remain in the abusive relationship.
Understanding why battered women do not “just leave” is key to
the delivery of compassionate and effective care.
See related articles on pp 737-46, 782-94, 800-2, and 804-5.
Fear
Battered women harbor legitimate fear for the physical safety of
themselves and dependent family members. Indeed, such women are well
aware that leaving does not necessarily mean safety. It is not
uncommon for a battered woman to report threats of harm or even death
against herself, her children, or other family members should she
attempt to leave. In fact, because the most dangerous time for a
battered woman is when she does attempt to leave, safety planning is
a key element in the care of such patients.
Financial Constraints
Battered women often lack access to the economic resources necessary
to gain and maintain independence. In addition to the increased
prevalence of violence seen in poorer women [10],
battered women are often denied access to liquid assets available to
their partners such as bank accounts, credit cards, and cash. It
is thus nearly impossible for such women to secure independent
credit, establish a new apartment or other living arrangement,
or simply afford the bus or taxi fare that is often necessary
to flee the batterer.
Social Isolation
Battered women tend to become progressively isolated from friends,
family, and community as they try to conform to rigid rules of
behavior within the household. The batterer often restricts or denies
the victim access to friends, family, the telephone, and even
commonly available media such as radio and television. As a result,
the battered woman becomes progressively isolated and dependent on
the batterer as her sole source of social and emotional support.
Feelings of Failure
Battered women frequently express emotions such as shame, humiliation,
low self-esteem, and feelings that she somehow caused her partner
to be abusive and thus deserves to be abused. Such profound
feelings of failure are too commonly reinforced by both explicit
and implicit messages, by individuals and groups, of the
responsibility of the battered woman not only to stay in the
relationship but also to try to make it better. Thus, the woman not
only feels ashamed of her situation but also of her inability to
change it. Recurring feelings of shame, worthlessness, and
helplessness often accompany reactive chronic depressive
symptoms.
Promises of Change
Episodes of violence are typically followed by a “honeymoon”
period of variable length. During the honeymoon phase, the batterer
often behaves in a manner that is construed as loving, tender,
apologetic, and remorseful and that is accompanied by promises
that he will change his behavior. These seemingly tranquil periods
are typically followed by an increase in tension, culminating
in a subsequent violent episode [21].
Despite the predictable nature of this “cycle of violence,” loving
and tender behavior between abusive episodes can serve as a powerful
force that often influences the battered woman to remain with her
abuser, in the hope that the violence will ultimately abate.
Unresponsive Support Network
Domestic violence is endemic in society and until recent years was
statutorily legal, affording women little protection under the law.
Although abuse prevention laws have been enacted in all 50 states,
intervention programs and legal protections for battered women and
their children remain less than adequate. More importantly,
community-based primary prevention and education programs, the most
essential cornerstones of a comprehensive, effective, and long-term
solution to violence in our society, are being de-emphasized,
down-sized, or even dismantled in the current economic and political
environment. Further-more, through frequent and graphic news and
entertainment media offerings, U.S. society has been desensitized to
the horrific effects of abuse. A culture in which violence is
normalized, bought, sold, and even admired cannot effectively respond
to the multifaceted problem of violence because it is constrained in
its ability to support effective community, state-wide, and national
responses.
Obstacles Patients Face in Approaching Physicians about
Violence and Abuse
Although the general public is now beginning to expect that
physicians know about domestic violence, most patients do not
believe their physician knows about the issue, would know what
to do, or even cares about domestic violence. Many patients are
reluctant to disclose, especially initially, because of shame, fear
of loss of confidentiality, or fear of reprisals from the batterer,
especially if the abuser uses the same physician or health care
facility. Some patients also feel they are not allowed to bring up an
issue, particularly one that is not “strictly medical,” unless
directly asked. As a corollary, subtle and usually unintentional
victim-blaming statements, minimization, and denial on the part of
some health care providers could reinforce the patient’s sense of
shame, humiliation, and responsibility about the violence and can
prevent some patients from seeking help in the health care setting.
Finally, some patients fear a denial or revocation of health,
disability, or life insurance benefits if their abuse is
discovered.
Although most battered patients do not volunteer a history of
violence to the physician unless directly asked, the rate of
disclosure increases substantially when routine inquiry is instituted
in an empathic, confidential, and non-judgmental manner [22-24].
However, physicians typically fail to ask about violence and
victimization during the medical encounter [25-27].
Thus, it is imperative that routine confidential inquiry become
part of the medical standard of care in primary care and
emergency practice settings.
| Clinical Evaluation Strategies
|
|---|
The
acronym “RADAR” Table
1 serves as a useful clinical practice tool for the physician.
Adhering to such an algorithm can promote a stream-lined, effective
response for both emergent and nonacute situations. The appropriate
role of the physician is as a member of an advocacy team that
includes essential community-based “experts,” health providers, and
legal resources. This team should be individually assembled for each
patient and should operate in a coordinated and supportive manner to
confidentially assist the patient in acquiring sufficient knowledge
and resources so that she can make informed choices about her own
(and her dependent children’s) health and safety. It should be
emphasized, particularly in cases of domestic or family violence,
that the appropriate role of the physician is not necessarily to
know all and do all but to screen, document, validate, and
refer.
|
The Patient Interview
Routinizing Inquiry
All patients, both female and male, should be asked about a
history of current or past abuse during the routine patient
interview and periodically thereafter. Although these questions
are awkward to ask at first, the physician rapidly adapts the
line of inquiry to his or her own personality and interview
style. It is often advisable to precede questioning about abuse
with a statement of awareness of the prevalence and seriousness
of domestic violence and that the physician is now asking all
patients about this important issue. I then ask, “At any time
[or in the case of a periodic or return visit, ‘in the last
year,’ or ‘since I last saw you’ …] has your
husband/boyfriend/partner/lover hit, kicked, threatened, or otherwise
hurt or frightened you?” It is important to be sensitive to the
possibility of intimate violence perpetrated by women in lesbian
relationships and by men in homosexual relationships, while
maintaining an awareness that some homosexual persons choose not to
disclose their sexual orientation to their physicians.
Following Through on Disclosure
If the patient discloses a history of abuse, the physician should
continue the inquiry, establishing a more detailed chronology
of the violence. Questioning about the first episode, the most
recent episode, and the most serious episode often helps the
physician quickly assess severity. The patient should be asked
about previous visits to emergency facilities for treatment,
threats, or injury with a weapon (blunt object, knife, or firearm).
The deleterious effects on children who witness physical violence
between their parents or caregivers is well documented [1,28].
Therefore, if children are living with the patient, it is important
to ask if the children have seen or heard threats or assaults
or have been threatened or assaulted themselves by the abuser.
The physician’s duty as a mandated reporter should be remembered
when issues of children at risk arise in the context of patient
care. In addition, the patient should be given time to tell her
story using an open-ended query format, with the physician
maintaining a compassionate, nonjudgmental stance.
Assuring Confidentiality
Confidentiality in the patient care setting must be assured and
honored [23],
not only because all physicianpatient communication should be
considered confidential [29],
but also because many battered women live in fear of serious injury
or death if anyone “finds out.” The patient should be interviewed in
a private setting, without the partner, children, neighborhood
interpreters, or anyone else known to the patient in attendance. The
patient will make the correct choice not to disclose, even in the
presence of ongoing abuse, if confidentiality cannot be assured.
Maintaining Advocacy
The patient should be validated and supported during the initial
interview and throughout the encounter. Statements such as “you
did not deserve to be hit/abused/beaten/threatened,” “violence
is never an acceptable way to resolve conflict,” “I am concerned
for your safety and well-being,” and simply, “I care about you
as my patient,” can help establish trust and confidence in the
physician-patient relationship and begin the initial process of
empowerment and healing for the patient.
Refraining from Blaming the
Patient
Although it is appropriate to ask what happened and how the
patient can get to safety if and when another violent episode
occurs (see below), the physician should never ask questions or
make statements that reinforce the patient’s sense of shame,
humiliation, blame, powerlessness, and failure. The following
are examples of such victim-blaming questions and statements:
“What do you think you might have done to bring on the violence?”;
“What could you have done to prevent the violence?”; “If it
were me, I wouldn’t stay with him”; “Why don’t you just leave
if he is battering you?”; “What keeps you with a person like
that?”; and “I just can’t help you any more if you aren’t going
to do something about your situation.”
Putting Aside the “Quick Fix”
Although the physician may wish his or her patient could get away
from the batterer, it is often not feasible or even possible for the
victim to leave. If a battered woman feels incapable of leaving the
abusive setting but is told by her physician that she must do so, she
will probably feel even more like a failure and risk being viewed as
a “noncompliant” patient. In fact, most battered women who leave have
unsuccessfully attempted to leave in the past.
Leaving the Door Open
Even in situations of ongoing domestic violence, some patients may
not disclose such information, even if asked directly, because of
fear of reprisals, shame, or fear of losing insurance benefits. The
patient may also mistrust the health care system in general. It is
therefore important, especially when suspicious findings are noted,
to leave the door open by saying, “I understand this is an issue you
may not want to talk about at this time, but in my experience as a
physician, when I see injuries or conditions such as yours, very
often it is because someone is being intentionally hurt, usually by a
partner. If this is the case, I stand ready to listen and to help you
when you are ready, and my office staff/nurse/social worker could
also help you with this in a manner that is strictly
confidential.”
The Physical Examination
Suspicious Findings
A woman who presents with any injury, particularly if she has
previously used emergency department facilities for any reason,
should be considered a victim of domestic violence until proven
otherwise. Such patients should undergo a careful physical
examination, and the examiner should suspect intentional violence,
particularly with respect to trauma in central areas of the body,
such as the face, abdomen, breasts, and genitals. The physician
should also especially consider bilateral or multiple injuries,
injuries that are in different stages of healing, and a delay
between the time of injury and arrival to the health care setting
as arising from intimate partner violence. Although injuries to
the central areas of the body predominate, contusions of the
ulnar aspects of the forearms are not uncommon; such injuries
usually result from blows sustained by the woman as she attempts
to protect her face from injury during an assault. In addition,
because sexual assault is not uncommon in intimate violence
situations, the physician should ask about and assess the patient
for such assault. Battered women often try to hide their injuries
with make-up or long clothes.
Inconsistencies between the Patient’s History and
the Physical Examination
In situations of domestic violence trauma, the patient’s explanation
of the injury is often inconsistent with the type and pattern
of injury. These patients usually do not feel comfortable disclosing
the cause of the violence unless directly asked in a nonjudgmental
manner that supports her safety and confidentiality.
Psychological and Somatic
Manifestations
Victims of domestic violence often present not with physical
injury but rather with chronic symptoms that are not accompanied
by discernible physical findings; these symptoms include headache,
shortness of breath, atypical chest pain, abdominal pain, pelvic
pain, musculoskeletal pain, dizziness, irritability, insomnia,
anxiety, panic symptoms, post-traumatic stress disorder, depression,
and alcohol or other substance abuse.
The Pregnant Patient
Because physical violence often begins or escalates during pregnancy,
particular consideration should be given to screening pregnant
women for current abuse. During each prenatal visit, the breasts
and abdominal area should be visually inspected for contusions,
and the patient should be asked, “Have you been hit, hurt, or
threatened since I last saw you in the office?”
Documentation in the Medical Record
Documentation of significant history and physical findings is an
important aspect of the care of battered patients. Whenever possible,
historical accounts should be recorded as written narratives of the
patient’s words. Physical findings can be documented using physician
narrative, labeled free-hand sketches or cartoon predrawn figures, or
instant photographs.
Documentation of domestic violence in the medical record can be a
source of invaluable information to a patient should she ever seek
legal redress from the batterer, if a prosecutor decides to proceed
in a criminal complaint with or without her testimony, or in a
potential custody dispute.
Assessment of Danger
Once a careful history and physical examination have been conducted,
the physician should then assess the patient’s short- and long-term
risk for injury or death. The most important determinants of
risk are the woman’s assessment of her immediate and future
danger, the presence of “crescendo violence” (that is, violence
that is increasing in frequency or severity), threats of homicide
or suicide by the partner, and the presence or availability of
a firearm or other lethal weapon. To assess the patient’s own sense
of danger, the physician should ask, “What is your sense of your
safety right now? Are you afraid to go home today?” Statements made
by the batterer to the patient such as “If you leave, I will find you
and kill you”; “If you leave, I will kill myself”; or “If you leave,
I will get the children and you will never see them again” should be
taken very seriously and acted on with urgency.
| Intervention Strategies
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|---|
The
physician has four main areas of responsibility in intervening in
domestic violence issues: 1) communicating concern and validating the
patient, 2) providing medical treatment, 3) reviewing options and
facilitating appropriate referral and follow-up, and 4) assuring the
generation of an individualized safety plan. Awareness and
acknowledgment that the patient has choices that will be respected
and resources that can be accessed can be a transforming and
empowering experience to a patient who has felt continually
victimized and powerless because of long-standing abuse.
Communicating Concern
Reassigning Accountability and
Responsibility
It is crucial to reframe the abuser’s violent behavior as unacceptable.
Empathic statements of concern and validation can serve as powerful
therapeutic tools and are easily used in the clinical encounter.
Acknowledging the Patient’s
Dilemma
If the patient cannot or is unwilling to disclose suspected
battering, or if she has disclosed such information but has
chosen not to leave the battering situation, the physician should
let her know that he or she will nonetheless remain available
to offer assistance and support. Phrases such as “You did not
deserve to be hit or hurt, no matter what happened”; “I am concerned
for your safety, and for the safety of your children”; “In my
experience, the violence does not go away, it generally gets
worse over time”; and most importantly, “I am here to advocate
for you and help you get to safety whenever you are ready to do
so” can be intensely powerful therapeutic tools in the office
setting.
Focusing on the Patient’s Strengths
A focus on the woman’s strengths in adverse circumstances, such as
managing the household, raising children, and taking prescribed
medications regularly, can be a positive therapeutic strategy
in view of the pervasive sense of failure and shame with which
most battered women live.
Providing Medical Treatment
Although the physician plays an important role in the multidisciplinary
hospital, office, and community team caring for battered women,
he or she is the only one who can direct and provide immediate
and follow-up medical care. Patients who present to emergency
settings should be referred for subsequent longitudinal care to
a primary care physician, preferably one who has training, expertise,
and sensitivity in caring for victims of intimate partner
violence.
Reviewing Options
Facilitating Referral
The physician should review the options available to the patient
and make appropriate referrals. Just as in the care of patients
with cancer, the physician should provide the patient with
information on available options and resources, as well as support in
making informed decisions regarding her care. The battered woman
may choose to return home to the abuser because she may not feel
ready or able to leave at the time of the encounter with the
physician. An emergency shelter (assuming available space) is
another option if the patient does not feel she can safely return
home.
So that optimal care is rendered and the burden on the physician
is minimized, each patient who is a victim of abuse should be
referred to a telephone hotline, a battered women’s advocate,
or a similar resource whenever possible. Battered women’s services,
usually originating from emergency shelters, are free, confidential,
expert, and empowering and can provide survivors of domestic
violence with vital follow-up care.
Cautionary Notes about Couples
Counseling
Couples counseling is contraindicated in cases of active domestic
violence [30].
Although practiced by some family therapists in cases in which the
level of violence is considered to be low [31],
couples counseling should be avoided in the primary care
setting.
Legal Referral
Many battered women can benefit from access to basic legal information
and assistance through referral to an attorney, court advocate,
or legal services center. The physician can serve a key role in
providing telephone numbers and support for the patient in this
regard.
The Safety Plan
The most dangerous time for a battered woman is when she decides
to leave her abuser. Ensuring that the patient has an individualized
safety plan is therefore a crucial and potentially life-saving
step. Although it is the physician’s responsibility to make
sure a safety plan is developed if disclosure occurs in the
health care setting, the actual formulation of the safety plan
can be somewhat time-consuming and is best accomplished with
the assistance of a skilled social worker, nurse, or battered
women’s advocate.
The safety plan should include the following elements: emergency
procedures, home safety, an abuse prevention order, safety on
the job and in public, and logistical issues [32].
Emergency Procedures
Emergency procedures should include a discussion about ways the
patient can attain safety during an explosive incident, such as which
rooms of the house to avoid (for example, the kitchen, where knives
are readily accessible, and the bedroom, where most firearms are
hidden and where most sexual assaults occur), how to exit rapidly and
safely, and how to alert a neighbor to call the police if an
altercation is overheard or if a special code or signal is
received.
Home Safety
A discussion about the following issues should be included:
changing door locks, installing a caller identification system
on the telephone or having an unpublished telephone number, and
letting the children know not to unlock the door for anyone,
including the batterer.
Abuse Prevention Order
An abuse prevention order, known in some states as an order of
protection or a restraining order, is a legal document issued by a
court of law, enforceable in most states by immediate arrest for
violation. The order is designed to protect an individual from abuse,
injury, or threat of injury by an intimate partner or relative. In
cases of domestic violence, the abuse prevention order should be
carried on the victim’s person at all times, and a copy should be
kept in a secure location elsewhere. Neighbors should be alerted to
the presence of such an order and instructed to contact the police if
the batterer attempts to confront the victim or enter the victim’s
property. The police should be informed of the nature of the call if
this occurs.
Workplace Safety
Because safety on the job is another important issue, the abuse
prevention order should be written to extend to the victim’s
work site, and coworkers, supervisors, and company security
should be alerted to its existence and provisions.
Logistical Considerations
Discussion regarding a place to which the victim can go that is
unknown to the batterer, how to get there, and essentials to have
packed (such as money, keys, medications, insurance and other cards,
and changes of clothes for the woman and her children) should be
included as part of the safety plan.
| Primary and Secondary Prevention in the Office Setting
|
|---|
Many
ways are available to bring effective primary and secondary
prevention into the office practice setting. First, clinical
office staff should receive periodic training on the basic dynamics
of the abusive relationship, as well as in office screening,
triage, and referral. Second, the office receptionist should be
provided with telephone numbers of local resources that can be given
to patients on request. Third, ancillary staff such as clerks,
parking lot attendants, and security personnel should be trained, as
appropriate to their position and skill, in basic domestic violence
awareness and response. Suspicious situations, such as yelling,
pushing, slapping, or other inappropriate behavior in the parking lot
or waiting area, should then be reported confidentially to the
physician or nurse. Fourth, posters, pamphlets, and other patient
education material should be available in the office reception area
and in private locations such as bathrooms and examination rooms.
Fifth, the physician should invite a discussion with the patient
about nonviolent alternatives for the resolution of conflict in the
home. These issues should be discussed with male and female patients
and can be an important component of creating an atmosphere of
primary prevention-oriented health advocacy for all patients.
A strong, consistent, and integrated message that the physician
and office staff are knowledgeable and concerned about domestic
violence can create a physician-patient atmosphere that
comprehensively yet efficiently addresses the issues at hand while
respecting the time demands placed on the practicing physician.
| Working Effectively with Victims of Abuse while Recognizing the Barriers That Physicians Face
|
|---|
Physicians
face many attitudinal and logistical obstacles in approaching the
care of battered women [1,33].
Sugg and Inui [1]
determined that the imagery of “opening Pandora’s box” was a common
reaction of physicians to the prospect of exploring issues of
domestic violence with patients. Although these barriers can
substantially affect the physician’s responsiveness to this problem,
they should not pose insurmountable obstacles to working effectively
in the care of battered patients. The following are barriers that
physicians face and their possible solutions.
The Fantasy of the Perfect Family
Many physicians who themselves have not experienced domestic
violence adhere to an idealized vision of the home and have
expressed difficulty approaching screening for domestic violence
in patients who come from socioeconomic and demographic backgrounds
similar to theirs. It is often difficult to acknowledge the
possibility of abuse in persons who are so much “like us” because
compassionate care requires an empathic response in the physician.
Recognition, through education and clinical experience, of the
prevalence and spectrum of abuse in different sociodemographic
groups can enable the physician to work more effectively and
empathically.
The Reality of the Imperfect Patient
Many battered women do not present to the health care setting as
“model” patients. The relatively high prevalence of psychological and
somatic sequelae of abuse (such as chronic pain symptoms, depression,
and alcoholism and other substance abuse), combined with frequent yet
often episodic use of health care services, serves to make many
battered patients less desirable in medical venues than patients who
present for regularly scheduled care on time, have one or a few
concrete issues, and rapidly get better with prescribed treatment. In
addition, physicians, not unlike other members of society, are
subject to stereotyped assumptions regarding domestic violence. The
following are examples of such assumptions: Domestic violence is
rare; domestic violence may occur but is seen mostly in other
physicians’ practices; intimate partner abuse does not occur in
families that appear “normal”; battered women have brought on the
abuse because of their behavior in the relationship; and finally, if
battered women don’t leave or if they subsequently return to the
abuser, the abuse was not very severe or a codependency within the
relationship makes the woman seek the abuse. Such stereotyped
assumptions can only undermine the ability of the physician to
provide optimal care. Recognition of the varied medical and
behavioral sequelae of abuse can enable the physician to work more
effectively and empathically. Unbiased, data-supported educational
initiatives combined with compassionate, non-judgmental attitudes can
dispel such value-laden myths. Educational initiatives must
encompass all phases of medical training and continuing medical
education and should also include training for office staff.
The Physician’s Previous Abuse
The physician may have been a victim of child physical or sexual
abuse or an adult victim, or perpetrator, of intimate violence.
In the study by Sugg and Inui [1],
14% of male physicians and 31% of female physicians acknowledged a
personal history of child abuse or of physical abuse as an adult. As
professional and personal supports become more available to
physicians, their own histories and recovery from abuse can be better
addressed, thus enabling improved patient care.
Fear of Offending Patients
Some physicians are reluctant to ask their patients about abuse,
fearing they may offend patients by asking about a topic that
society considers a private matter, one that should stay “behind
closed doors.” Most patients are grateful to their physicians
who routinely inquire about violence and abuse in relationships
and do not consider this line of inquiry to be offensive or
intrusive. Addressing issues of violence and abuse is generally
welcomed by patients, who look to their physicians for advice
and support in areas in which the physician feels competent to
engage.
Powerlessness and Lack of Control
Physicians often feel overwhelmed by the size of the problem and
helpless in their efforts to be effective in bringing about any type
of meaningful change in a battered patient’s life. In addition,
although willing to screen, identify, treat, and refer victims of
intimate partner abuse, many physicians are frustrated with their
inability to direct the outcome and with their patients’ inability to
effect meaningful changes in their life circumstances. The lack of
easily identifiable therapeutic tools, combined with the complex
medical, social, and behavioral issues at play, usually make an easy
diagnosis and quick fix untenable in instances of domestic violence.
The ability of the physician to function as a member of a
multidisciplinary team, use available community resources, and
understand that the most appropriate treatment should consider the
patient’s individual needs in the context of her own life
circumstances is important in addressing the physician’s feelings of
powerlessness and lack of control.
Lack of Education
Most practicing physicians have received no education in domestic
violence during medical school, postgraduate training, or continuing
medical education. The lack of basic knowledge and skill in
this area is closely related to many of the other physician
barriers described above. Domestic violence is only now becoming
recognized as a problem that is appropriately addressed in the
health care setting and taught in educational venues. Core competency
in knowledge, skill, and attitudes in primary prevention and in
caring for victims of intimate partner violence should be included in
undergraduate medical education and postgraduate training.
High-quality, skill-based continuing medical education programs
should be available to physicians in practice and encouraged through
specialty societies and organized medicine.
Fear of Precipitating More Violence
Given the known increase in danger to the victim when she decides
to leave an abusive relationship, some physicians are reluctant
to risk doing more harm by advocating on behalf of a battered
woman, empowering her to decide to leave, and thus potentially
precipitating nonlethal injury or even homicide. Safety planning
should be incorporated into the treatment strategy for every
current victim of domestic violence. Such safety planning is
best done with an expert in crisis intervention in domestic
violence, usually a battered women’s advocate.
The Tyranny of Time
Time constraints can be a formidable barrier to doing effective
work with battered patients. Many physicians feel they have
inadequate time to intervene effectively if a patient discloses
abuse. Others voice frustration that having to ask about “one
more thing” will be too burdensome in a clinical encounter that
is already full. Clearly, a crisis situation in domestic violence,
similar to a cardiac crisis or the exigencies of dealing with
an acutely suicidal patient, needs to be triaged appropriately
and expeditiously. Professional and community colleagues who
can be contacted rapidly, the availability and use of patient
education materials, and the implementation of updated office
protocols can minimize the disruption in office routine when a
diagnosis of current domestic violence is established. In the setting
of routine patient care, questioning about violence in relationships
can be easily incorporated into the periodic history and physical
examination, along with a message of compassion, empathy, and concern
about the issue. This simple message of care can have a tremendously
positive effect on the physician-patient relationship overall and may
even improve the flow and efficiency of patient care.
Isolation
Physicians who try to provide solo care for victims of domestic
violence are doing both themselves and their patients a disservice.
This work can be stressful, emotionally draining, and disturbing
and should not be under-taken in isolation. Physicians are encouraged
to develop a support network in the local community; to share
the burden of active cases; and to offer mutual supervision,
support, and collegiality.
Office Security and Personal Safety
Although not mentioned as a barrier by the physicians responding
in Sugg and Inui’s study [1],
other physicians have voiced reluctance to ask about or intervene in
situations of domestic violence, out of concern for their own
personal safety or that of their office staff. I know of no reports
of health care workers being threatened, injured, or killed by the
partners of patients who are victims of domestic violence. However,
the potential risks to office staff must be considered in any
potentially volatile situation. The contract of care is between the
physician and the patient. When the patient is a victim of domestic
abuse, the perpetrator should not be contacted or confronted in
the office setting. In addition, training for office personnel
on recognizing and responding to domestic violence issues, and
in assuring strict patient confidentiality, is encouraged. Emergency
procedures should be outlined and practiced in the office setting
for potential emergencies in domestic violence, as well as in
other situations.
Summary
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In
conclusion, the short- and long-term effects of domestic violence are
health care issues that nearly every practicing physician encounters
in the course of routine clinical practice. Physicians are now
expected to know the basics of recognition and intervention related
to primary prevention, early intervention, and crisis care of victims
of domestic violence. The importance of routinely integrating
questioning about violent conflict and intervention into office
practice, particularly in generalist fields such as internal
medicine, are important components of the new agenda for health care
in the twenty-first century.
Requests for Reprints: Elaine J. Alpert, MD, Boston University
School of Medicine, 80 East Concord Street, Boston, MA 02118-2394.
| Author and Article Information
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| TopSummaryAuthor & Article InfoReferences |
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From Boston University
School of Medicine, Boston, Massachusetts. For the current author address, see
end of text.
References
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