{"id":1521,"date":"2013-10-11T09:06:18","date_gmt":"2013-10-11T09:06:18","guid":{"rendered":"http:\/\/jacobimed.org\/NS\/?page_id=1521"},"modified":"2013-10-11T09:06:18","modified_gmt":"2013-10-11T09:06:18","slug":"violence-in-intimate-relationships-and-the-practicing-internist","status":"publish","type":"page","link":"https:\/\/jacobimed.org\/old\/ambulatory\/mlove\/curriculumwomengeri-2\/domestic-violence\/domestic-violence-articles\/violence-in-intimate-relationships-and-the-practicing-internist\/","title":{"rendered":"Violence in Intimate Relationships and the Practicing Internist"},"content":{"rendered":"

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Articles in PubMed by Author:<\/strong><\/span> <\/p>\n\n\n\n\n\n\n\n\n\n\n
  <\/td>\nAlpert, E. J.<\/a><\/span><\/td>\n<\/tr>\n
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\n<\/span><\/p>\n

DIAGNOSIS AND TREATMENT<\/span><\/span><\/h4>\n

Violence in Intimate Relationships and the Practicing Internist <\/span><\/h2>\n

New “Disease” or New Agenda? <\/span><\/h3>\n

<\/a> Elaine J.
\nAlpert, MD, MPH <\/span><\/a>
\n<\/span><\/p>\n

15 November 1995 | Volume 123 Issue 10 | Pages
\n774-781<\/strong><\/span>
\n<\/span><\/p>\n

Domestic violence is endemic in U.S. society and is seen
\nin <\/sup>nearly every venue of medical care. A history of abuse should
\n<\/sup>be considered and routinely queried in all women who present
\n<\/sup>for emergency care, should be suspected in any woman who presents
\n<\/sup>with an injury, and should be routinely screened for in primary
\n<\/sup>care settings. <\/sup>
\n<\/span><\/span><\/p>\n


\n<\/span><\/p>\n

\n

\nClinical
\nmanifestations, suggested diagnostic strategies, obstacles <\/sup>to leaving
\nthe abusive relationship, and the barriers that patients <\/sup>face in
\nobtaining and that physicians face in providing optimal <\/sup>care in
\nsituations of domestic violence are discussed. Physicians <\/sup>can play a
\npivotal role in primary prevention, early intervention, <\/sup>and follow-up
\ncare during and after an episode of intimate partner <\/sup>violence.
\nClinical competence in the treatment and prevention <\/sup>of family
\nviolence is an important component of the new agenda <\/sup>for health care,
\nparticularly in generalist fields such as general <\/sup>internal
\nmedicine. <\/sup>
\n<\/span><\/span><\/p>\n

Ann Intern Med. 1995;123:774-781. <\/sup>
\n<\/span><\/span><\/p>\n

Core competence in screening, recognizing, and treating the <\/sup>short-
\nand long-term manifestations of violence in intimate <\/sup>relationships is
\nincreasingly expected as the standard of care <\/sup>for internists and
\nother generalist and specialist physicians. <\/sup>Yet, most practicing
\nphysicians have received no education or <\/sup>training in this area during
\nmedical school, residency training, <\/sup>or continuing education [1-4]<\/a>.
\n<\/sup>
\n<\/span><\/span><\/p>\n

The objectives of this paper are the following: 1) to help physicians
\n<\/sup>better recognize and understand the spectrum of clinical
\nmanifestations <\/sup>of intimate partner violence; 2) to introduce and
\nreinforce <\/sup>the concept of routine periodic inquiry regarding current,
\npast, <\/sup>or potential victimization as a component of standard
\npatient <\/sup>care in generalist and subspecialist practice; 3) to
\ndiscuss <\/sup>the range of difficulties that battered women face in
\nleaving <\/sup>abusive relationships and in accessing and interacting
\nwith <\/sup>the health care system; 4) to discuss the logistic and
\nattitudinal <\/sup>barriers that physicians face when confronting issues of
\nviolence <\/sup>and abuse in their practice settings; 5) to summarize for
\npracticing <\/sup>physicians the skills that can be used in the care of
\npatients <\/sup>who may be at risk for or suffering the effects of
\nintimate <\/sup>partner violence; and 6) to enable physicians to gain a
\nnew <\/sup>understanding of violence in the context of the life cycle
\nof <\/sup>the patient as a member of a family and community and of the
\n<\/sup>medical, social, and cultural contexts of violence as learned
\n<\/sup>behavior in our society. <\/sup>
\n<\/span><\/span><\/p>\n

<\/a><\/p>\n\n\n\n
Background and
\n Definitions <\/span><\/p>\n\n\n\n
<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<\/th>\n<\/tr>\n<\/tbody>\n<\/table>\n

Relationship
\nviolence can be defined as intentional violent <\/sup>or controlling
\nbehavior in the context of an intimate relationship <\/sup>[5]<\/a>.
\nAlthough most victims of domestic violence are women in <\/sup>heterosexual
\nrelationships [6]<\/a>,
\nthe incidence and prevalence <\/sup>of domestic violence appear to be
\nsimilar in male and female <\/sup>homosexual relationships [7,8]<\/a>.
\nThis finding underscores the <\/sup>predominant constructs of power and
\ncontrol in this syndrome <\/sup>as opposed to gender. Thus, violence
\nthroughout the human life <\/sup>cycle, expressed as child abuse and
\nneglect, dating violence, <\/sup>domestic violence, elder abuse, and abuse
\nof the disabled can <\/sup>be viewed as learned behavior manifested to
\nassert power and <\/sup>maintain control. <\/sup>
\n<\/span><\/span><\/p>\n

Domestic violence encompasses not only physical injury but also
\n<\/sup>threats, sexual abuse, emotional and psychological torment,
\n<\/sup>economic control, and progressive social isolation [9]<\/a>.
\nIn fact, <\/sup>physical violence usually occurs in the setting of a
\nprodrome <\/sup>of nonassaultive behaviors, which can occur in any
\ncombination <\/sup>over a varying time course. <\/sup>
\n<\/span><\/span><\/p>\n

Risk Factors and Clinical
\nCharacteristics<\/span><\/strong>
\n<\/span><\/span><\/p>\n

It is widely acknowledged that domestic violence is prevalent <\/sup>in
\nall racial, educational, geographic, and socioeconomic segments <\/sup>of
\nsociety. Various clinical and demographic characteristics <\/sup>of women
\nwho are currently being physically abused have been <\/sup>elucidated in the
\nstudy by McCauley and colleagues in this issue <\/sup>of Annals [10]<\/a>.
\nIn addition to acute physical trauma, domestic <\/sup>violence is associated
\nwith many physical and psychological <\/sup>sequelae, including multiple
\nsomatic symptoms [11]<\/a>;
\nchronic <\/sup>abdominal pain [12]<\/a>;
\nchronic headaches [13]<\/a>;
\npelvic pain [14,15]<\/a>;
\n<\/sup>and anxiety, depression, post-traumatic stress syndromes, and
\n<\/sup>other psychiatric disorders [16]<\/a>.
\nAlcohol and drug addiction, <\/sup>musculoskeletal symptoms, and eating
\ndisorders are other health-related <\/sup>sequelae of short- and long-term
\nabuse [17]<\/a>.
\nPhysical violence <\/sup>seems to be particularly common during pregnancy,
\nwith prevalence <\/sup>estimates ranging from 16% to 37% [18-20]<\/a>.
\n<\/sup>
\n<\/span><\/span><\/p>\n

Obstacles to Leaving an Abusive
\nRelationship<\/span><\/strong>
\n<\/span><\/span><\/p>\n

Many battered women endure a pattern of progressively escalating
\n<\/sup>violence over months to years but remain in the abusive relationship.
\n<\/sup>Understanding why battered women do not “just leave” is key <\/sup>to
\nthe delivery of compassionate and effective care. <\/sup>
\n<\/span><\/span><\/p>\n

See related articles on pp 737-46, 782-94, 800-2, and 804-5. <\/sup>
\n<\/span><\/span><\/p>\n

Fear<\/span><\/strong>
\n<\/span><\/span><\/p>\n

Battered women harbor legitimate fear for the physical safety <\/sup>of
\nthemselves and dependent family members. Indeed, such women <\/sup>are well
\naware that leaving does not necessarily mean safety. <\/sup>It is not
\nuncommon for a battered woman to report threats of <\/sup>harm or even death
\nagainst herself, her children, or other family <\/sup>members should she
\nattempt to leave. In fact, because the most <\/sup>dangerous time for a
\nbattered woman is when she does attempt <\/sup>to leave, safety planning is
\na key element in the care of such <\/sup>patients. <\/sup>
\n<\/span><\/span><\/p>\n

Financial Constraints<\/span><\/strong>
\n<\/span><\/span><\/p>\n

Battered women often lack access to the economic resources necessary
\n<\/sup>to gain and maintain independence. In addition to the increased
\n<\/sup>prevalence of violence seen in poorer women [10]<\/a>,
\nbattered women <\/sup>are often denied access to liquid assets available to
\ntheir <\/sup>partners such as bank accounts, credit cards, and cash. It
\nis <\/sup>thus nearly impossible for such women to secure independent
\n<\/sup>credit, establish a new apartment or other living arrangement,
\n<\/sup>or simply afford the bus or taxi fare that is often necessary
\n<\/sup>to flee the batterer. <\/sup>
\n<\/span><\/span><\/p>\n

Social Isolation<\/span><\/strong>
\n<\/span><\/span><\/p>\n

Battered women tend to become progressively isolated from friends,
\n<\/sup>family, and community as they try to conform to rigid rules <\/sup>of
\nbehavior within the household. The batterer often restricts <\/sup>or denies
\nthe victim access to friends, family, the telephone, <\/sup>and even
\ncommonly available media such as radio and television. <\/sup>As a result,
\nthe battered woman becomes progressively isolated <\/sup>and dependent on
\nthe batterer as her sole source of social and <\/sup>emotional support.
\n<\/sup>
\n<\/span><\/span><\/p>\n

Feelings of Failure<\/span><\/strong>
\n<\/span><\/span><\/p>\n

Battered women frequently express emotions such as shame, humiliation,
\n<\/sup>low self-esteem, and feelings that she somehow caused her partner
\n<\/sup>to be abusive and thus deserves to be abused. Such profound
\n<\/sup>feelings of failure are too commonly reinforced by both explicit
\n<\/sup>and implicit messages, by individuals and groups, of the
\nresponsibility <\/sup>of the battered woman not only to stay in the
\nrelationship but <\/sup>also to try to make it better. Thus, the woman not
\nonly feels <\/sup>ashamed of her situation but also of her inability to
\nchange <\/sup>it. Recurring feelings of shame, worthlessness, and
\nhelplessness <\/sup>often accompany reactive chronic depressive
\nsymptoms. <\/sup>
\n<\/span><\/span><\/p>\n

Promises of Change<\/span><\/strong>
\n<\/span><\/span><\/p>\n

Episodes of violence are typically followed by a “honeymoon”
\n<\/sup>period of variable length. During the honeymoon phase, the batterer
\n<\/sup>often behaves in a manner that is construed as loving, tender,
\n<\/sup>apologetic, and remorseful and that is accompanied by promises
\n<\/sup>that he will change his behavior. These seemingly tranquil periods
\n<\/sup>are typically followed by an increase in tension, culminating
\n<\/sup>in a subsequent violent episode [21]<\/a>.
\nDespite the predictable <\/sup>nature of this “cycle of violence,” loving
\nand tender behavior <\/sup>between abusive episodes can serve as a powerful
\nforce that <\/sup>often influences the battered woman to remain with her
\nabuser, <\/sup>in the hope that the violence will ultimately abate.
\n<\/sup>
\n<\/span><\/span><\/p>\n

Unresponsive Support Network<\/span><\/strong>
\n<\/span><\/span><\/p>\n

Domestic violence is endemic in society and until recent years <\/sup>was
\nstatutorily legal, affording women little protection under <\/sup>the law.
\nAlthough abuse prevention laws have been enacted in <\/sup>all 50 states,
\nintervention programs and legal protections for <\/sup>battered women and
\ntheir children remain less than adequate. <\/sup>More importantly,
\ncommunity-based primary prevention and education <\/sup>programs, the most
\nessential cornerstones of a comprehensive, <\/sup>effective, and long-term
\nsolution to violence in our society, <\/sup>are being de-emphasized,
\ndown-sized, or even dismantled in the <\/sup>current economic and political
\nenvironment. Further-more, through <\/sup>frequent and graphic news and
\nentertainment media offerings, <\/sup>U.S. society has been desensitized to
\nthe horrific effects of <\/sup>abuse. A culture in which violence is
\nnormalized, bought, sold, <\/sup>and even admired cannot effectively respond
\nto the multifaceted <\/sup>problem of violence because it is constrained in
\nits ability <\/sup>to support effective community, state-wide, and national
\nresponses. <\/sup>
\n<\/span><\/span><\/p>\n

Obstacles Patients Face in Approaching Physicians about
\nViolence and Abuse<\/span><\/strong>
\n<\/span><\/span><\/p>\n

Although the general public is now beginning to expect that
\n<\/sup>physicians know about domestic violence, most patients do not
\n<\/sup>believe their physician knows about the issue, would know what
\n<\/sup>to do, or even cares about domestic violence. Many patients <\/sup>are
\nreluctant to disclose, especially initially, because of <\/sup>shame, fear
\nof loss of confidentiality, or fear of reprisals <\/sup>from the batterer,
\nespecially if the abuser uses the same physician <\/sup>or health care
\nfacility. Some patients also feel they are not <\/sup>allowed to bring up an
\nissue, particularly one that is not “strictly <\/sup>medical,” unless
\ndirectly asked. As a corollary, subtle and <\/sup>usually unintentional
\nvictim-blaming statements, minimization, <\/sup>and denial on the part of
\nsome health care providers could reinforce <\/sup>the patient’s sense of
\nshame, humiliation, and responsibility <\/sup>about the violence and can
\nprevent some patients from seeking <\/sup>help in the health care setting.
\nFinally, some patients fear <\/sup>a denial or revocation of health,
\ndisability, or life insurance <\/sup>benefits if their abuse is
\ndiscovered. <\/sup>
\n<\/span><\/span><\/p>\n

Although most battered patients do not volunteer a history of
\n<\/sup>violence to the physician unless directly asked, the rate of
\n<\/sup>disclosure increases substantially when routine inquiry is instituted
\n<\/sup>in an empathic, confidential, and non-judgmental manner [22-24]<\/a>.
\n<\/sup>However, physicians typically fail to ask about violence and
\n<\/sup>victimization during the medical encounter [25-27]<\/a>.
\nThus, it <\/sup>is imperative that routine confidential inquiry become
\npart <\/sup>of the medical standard of care in primary care and
\nemergency <\/sup>practice settings. <\/sup>
\n<\/span><\/span><\/p>\n

<\/a><\/p>\n\n\n\n
Clinical Evaluation
\n Strategies <\/span><\/p>\n\n\n\n
<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<\/th>\n<\/tr>\n<\/tbody>\n<\/table>\n

The
\nacronym “RADAR” Table
\n1<\/a> serves as a useful clinical practice <\/sup>tool for the physician.
\nAdhering to such an algorithm can promote <\/sup>a stream-lined, effective
\nresponse for both emergent and nonacute <\/sup>situations. The appropriate
\nrole of the physician is as a member <\/sup>of an advocacy team that
\nincludes essential community-based <\/sup>“experts,” health providers, and
\nlegal resources. This team <\/sup>should be individually assembled for each
\npatient and should <\/sup>operate in a coordinated and supportive manner to
\nconfidentially <\/sup>assist the patient in acquiring sufficient knowledge
\nand resources <\/sup>so that she can make informed choices about her own
\n(and her <\/sup>dependent children’s) health and safety. It should be
\nemphasized, <\/sup>particularly in cases of domestic or family violence,
\nthat the <\/sup>appropriate role of the physician is not necessarily to
\nknow <\/sup>all and do all but to screen, document, validate, and
\nrefer. <\/sup>
\n<\/span><\/span><\/p>\n

<\/a>
\n<\/span><\/span><\/p>\n\n\n\n
\n\n\n\n
View
\n this table:<\/strong>
[in
\n this window]<\/a>
[in a new window]<\/a>
  <\/span><\/td>\n		Table 1. Using
\n RADAR<\/strong>
\n <\/span><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

 
\n<\/span><\/span><\/p>\n

The Patient Interview<\/span><\/strong>
\n<\/span><\/span><\/p>\n


\n<\/span><\/span><\/p>\n

Routinizing Inquiry<\/strong><\/span>
\n<\/span><\/span><\/p>\n

All patients, both female and male, should be asked about a
\n<\/sup>history of current or past abuse during the routine patient
\n<\/sup>interview and periodically thereafter. Although these questions
\n<\/sup>are awkward to ask at first, the physician rapidly adapts the
\n<\/sup>line of inquiry to his or her own personality and interview
\n<\/sup>style. It is often advisable to precede questioning about abuse
\n<\/sup>with a statement of awareness of the prevalence and seriousness
\n<\/sup>of domestic violence and that the physician is now asking all
\n<\/sup>patients about this important issue. I then ask, “At any time
\n<\/sup>[or in the case of a periodic or return visit, ‘in the last
\n<\/sup>year,’ or ‘since I last saw you’ …] has your
\nhusband\/boyfriend\/partner\/lover <\/sup>hit, kicked, threatened, or otherwise
\nhurt or frightened you?” <\/sup>It is important to be sensitive to the
\npossibility of intimate <\/sup>violence perpetrated by women in lesbian
\nrelationships and by <\/sup>men in homosexual relationships, while
\nmaintaining an awareness <\/sup>that some homosexual persons choose not to
\ndisclose their sexual <\/sup>orientation to their physicians. <\/sup>
\n<\/span><\/span><\/p>\n

Following Through on Disclosure<\/strong><\/span>
\n<\/span><\/span><\/p>\n

If the patient discloses a history of abuse, the physician should
\n<\/sup>continue the inquiry, establishing a more detailed chronology
\n<\/sup>of the violence. Questioning about the first episode, the most
\n<\/sup>recent episode, and the most serious episode often helps the
\n<\/sup>physician quickly assess severity. The patient should be asked
\n<\/sup>about previous visits to emergency facilities for treatment,
\n<\/sup>threats, or injury with a weapon (blunt object, knife, or firearm).
\n<\/sup>The deleterious effects on children who witness physical violence
\n<\/sup>between their parents or caregivers is well documented [1,28]<\/a>.
\n<\/sup>Therefore, if children are living with the patient, it is important
\n<\/sup>to ask if the children have seen or heard threats or assaults
\n<\/sup>or have been threatened or assaulted themselves by the abuser.
\n<\/sup>The physician’s duty as a mandated reporter should be remembered
\n<\/sup>when issues of children at risk arise in the context of patient
\n<\/sup>care. In addition, the patient should be given time to tell <\/sup>her
\nstory using an open-ended query format, with the physician
\n<\/sup>maintaining a compassionate, nonjudgmental stance. <\/sup>
\n<\/span><\/span><\/p>\n

Assuring Confidentiality<\/strong><\/span>
\n<\/span><\/span><\/p>\n

Confidentiality in the patient care setting must be assured <\/sup>and
\nhonored [23]<\/a>,
\nnot only because all physicianpatient communication <\/sup>should be
\nconsidered confidential [29]<\/a>,
\nbut also because many <\/sup>battered women live in fear of serious injury
\nor death if anyone <\/sup>“finds out.” The patient should be interviewed in
\na private <\/sup>setting, without the partner, children, neighborhood
\ninterpreters, <\/sup>or anyone else known to the patient in attendance. The
\npatient <\/sup>will make the correct choice not to disclose, even in the
\npresence <\/sup>of ongoing abuse, if confidentiality cannot be assured.
\n<\/sup>
\n<\/span><\/span><\/p>\n

Maintaining Advocacy<\/strong><\/span>
\n<\/span><\/span><\/p>\n

The patient should be validated and supported during the initial
\n<\/sup>interview and throughout the encounter. Statements such as “you
\n<\/sup>did not deserve to be hit\/abused\/beaten\/threatened,” “violence
\n<\/sup>is never an acceptable way to resolve conflict,” “I am concerned
\n<\/sup>for your safety and well-being,” and simply, “I care about you
\n<\/sup>as my patient,” can help establish trust and confidence in the
\n<\/sup>physician-patient relationship and begin the initial process <\/sup>of
\nempowerment and healing for the patient. <\/sup>
\n<\/span><\/span><\/p>\n

Refraining from Blaming the
\nPatient<\/strong><\/span>
\n<\/span><\/span><\/p>\n

Although it is appropriate to ask what happened and how the
\n<\/sup>patient can get to safety if and when another violent episode
\n<\/sup>occurs (see below), the physician should never ask questions <\/sup>or
\nmake statements that reinforce the patient’s sense of shame,
\n<\/sup>humiliation, blame, powerlessness, and failure. The following
\n<\/sup>are examples of such victim-blaming questions and statements:
\n<\/sup>“What do you think you might have done to bring on the violence?”;
\n<\/sup>“What could you have done to prevent the violence?”; “If it
\n<\/sup>were me, I wouldn’t stay with him”; “Why don’t you just leave
\n<\/sup>if he is battering you?”; “What keeps you with a person like
\n<\/sup>that?”; and “I just can’t help you any more if you aren’t going
\n<\/sup>to do something about your situation.” <\/sup>
\n<\/span><\/span><\/p>\n

Putting Aside the “Quick Fix”<\/strong><\/span>
\n<\/span><\/span><\/p>\n

Although the physician may wish his or her patient could get <\/sup>away
\nfrom the batterer, it is often not feasible or even possible <\/sup>for the
\nvictim to leave. If a battered woman feels incapable <\/sup>of leaving the
\nabusive setting but is told by her physician <\/sup>that she must do so, she
\nwill probably feel even more like a <\/sup>failure and risk being viewed as
\na “noncompliant” patient. In <\/sup>fact, most battered women who leave have
\nunsuccessfully attempted <\/sup>to leave in the past. <\/sup>
\n<\/span><\/span><\/p>\n

Leaving the Door Open<\/strong><\/span>
\n<\/span><\/span><\/p>\n

Even in situations of ongoing domestic violence, some patients <\/sup>may
\nnot disclose such information, even if asked directly, because <\/sup>of
\nfear of reprisals, shame, or fear of losing insurance benefits. <\/sup>The
\npatient may also mistrust the health care system in general. <\/sup>It is
\ntherefore important, especially when suspicious findings <\/sup>are noted,
\nto leave the door open by saying, “I understand this <\/sup>is an issue you
\nmay not want to talk about at this time, but <\/sup>in my experience as a
\nphysician, when I see injuries or conditions <\/sup>such as yours, very
\noften it is because someone is being intentionally <\/sup>hurt, usually by a
\npartner. If this is the case, I stand ready <\/sup>to listen and to help you
\nwhen you are ready, and my office <\/sup>staff\/nurse\/social worker could
\nalso help you with this in a <\/sup>manner that is strictly
\nconfidential.” <\/sup>
\n<\/span><\/span><\/p>\n

The Physical Examination<\/span><\/strong>
\n<\/span><\/span><\/p>\n

Suspicious Findings<\/strong><\/span>
\n<\/span><\/span><\/p>\n

A woman who presents with any injury, particularly if she has
\n<\/sup>previously used emergency department facilities for any reason,
\n<\/sup>should be considered a victim of domestic violence until proven
\n<\/sup>otherwise. Such patients should undergo a careful physical
\nexamination, <\/sup>and the examiner should suspect intentional violence,
\nparticularly <\/sup>with respect to trauma in central areas of the body,
\nsuch as <\/sup>the face, abdomen, breasts, and genitals. The physician
\nshould <\/sup>also especially consider bilateral or multiple injuries,
\ninjuries <\/sup>that are in different stages of healing, and a delay
\nbetween <\/sup>the time of injury and arrival to the health care setting
\nas <\/sup>arising from intimate partner violence. Although injuries to
\n<\/sup>the central areas of the body predominate, contusions of the
\n<\/sup>ulnar aspects of the forearms are not uncommon; such injuries
\n<\/sup>usually result from blows sustained by the woman as she attempts
\n<\/sup>to protect her face from injury during an assault. In addition,
\n<\/sup>because sexual assault is not uncommon in intimate violence
\n<\/sup>situations, the physician should ask about and assess the patient
\n<\/sup>for such assault. Battered women often try to hide their injuries
\n<\/sup>with make-up or long clothes. <\/sup>
\n<\/span><\/span><\/p>\n

Inconsistencies between the Patient’s History and
\nthe Physical Examination<\/strong><\/span>
\n<\/span><\/span><\/p>\n

In situations of domestic violence trauma, the patient’s explanation
\n<\/sup>of the injury is often inconsistent with the type and pattern
\n<\/sup>of injury. These patients usually do not feel comfortable disclosing
\n<\/sup>the cause of the violence unless directly asked in a nonjudgmental
\n<\/sup>manner that supports her safety and confidentiality. <\/sup>
\n<\/span><\/span><\/p>\n

Psychological and Somatic
\nManifestations<\/strong><\/span>
\n<\/span><\/span><\/p>\n

Victims of domestic violence often present not with physical
\n<\/sup>injury but rather with chronic symptoms that are not accompanied
\n<\/sup>by discernible physical findings; these symptoms include headache,
\n<\/sup>shortness of breath, atypical chest pain, abdominal pain, pelvic
\n<\/sup>pain, musculoskeletal pain, dizziness, irritability, insomnia,
\n<\/sup>anxiety, panic symptoms, post-traumatic stress disorder, depression,
\n<\/sup>and alcohol or other substance abuse. <\/sup>
\n<\/span><\/span><\/p>\n

The Pregnant Patient<\/strong><\/span>
\n<\/span><\/span><\/p>\n

Because physical violence often begins or escalates during pregnancy,
\n<\/sup>particular consideration should be given to screening pregnant
\n<\/sup>women for current abuse. During each prenatal visit, the breasts
\n<\/sup>and abdominal area should be visually inspected for contusions,
\n<\/sup>and the patient should be asked, “Have you been hit, hurt, or
\n<\/sup>threatened since I last saw you in the office?” <\/sup>
\n<\/span><\/span><\/p>\n

Documentation in the Medical Record<\/span><\/strong>
\n<\/span><\/span><\/p>\n

Documentation of significant history and physical findings is <\/sup>an
\nimportant aspect of the care of battered patients. Whenever <\/sup>possible,
\nhistorical accounts should be recorded as written <\/sup>narratives of the
\npatient’s words. Physical findings can be <\/sup>documented using physician
\nnarrative, labeled free-hand sketches <\/sup>or cartoon predrawn figures, or
\ninstant photographs. <\/sup>
\n<\/span><\/span><\/p>\n

Documentation of domestic violence in the medical record can <\/sup>be a
\nsource of invaluable information to a patient should she <\/sup>ever seek
\nlegal redress from the batterer, if a prosecutor decides <\/sup>to proceed
\nin a criminal complaint with or without her testimony, <\/sup>or in a
\npotential custody dispute. <\/sup>
\n<\/span><\/span><\/p>\n

Assessment of Danger<\/span><\/strong>
\n<\/span><\/span><\/p>\n

Once a careful history and physical examination have been conducted,
\n<\/sup>the physician should then assess the patient’s short- and long-term
\n<\/sup>risk for injury or death. The most important determinants of
\n<\/sup>risk are the woman’s assessment of her immediate and future
\n<\/sup>danger, the presence of “crescendo violence” (that is, violence
\n<\/sup>that is increasing in frequency or severity), threats of homicide
\n<\/sup>or suicide by the partner, and the presence or availability <\/sup>of
\na firearm or other lethal weapon. To assess the patient’s <\/sup>own sense
\nof danger, the physician should ask, “What is your <\/sup>sense of your
\nsafety right now? Are you afraid to go home today?” <\/sup>Statements made
\nby the batterer to the patient such as “If you <\/sup>leave, I will find you
\nand kill you”; “If you leave, I will <\/sup>kill myself”; or “If you leave,
\nI will get the children and <\/sup>you will never see them again” should be
\ntaken very seriously <\/sup>and acted on with urgency. <\/sup>
\n<\/span><\/span><\/p>\n

<\/a><\/p>\n\n\n\n
Intervention
\n Strategies <\/span><\/p>\n\n\n\n
<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<\/th>\n<\/tr>\n<\/tbody>\n<\/table>\n

The
\nphysician has four main areas of responsibility in intervening <\/sup>in
\ndomestic violence issues: 1) communicating concern and validating <\/sup>the
\npatient, 2) providing medical treatment, 3) reviewing options <\/sup>and
\nfacilitating appropriate referral and follow-up, and 4) <\/sup>assuring the
\ngeneration of an individualized safety plan. Awareness <\/sup>and
\nacknowledgment that the patient has choices that will be <\/sup>respected
\nand resources that can be accessed can be a transforming <\/sup>and
\nempowering experience to a patient who has felt continually
\n<\/sup>victimized and powerless because of long-standing abuse. <\/sup>
\n<\/span><\/span><\/p>\n

Communicating Concern<\/span><\/strong>
\n<\/span><\/span><\/p>\n

Reassigning Accountability and
\nResponsibility<\/strong><\/span>
\n<\/span><\/span><\/p>\n

It is crucial to reframe the abuser’s violent behavior as unacceptable.
\n<\/sup>Empathic statements of concern and validation can serve as powerful
\n<\/sup>therapeutic tools and are easily used in the clinical encounter.
\n<\/sup>
\n<\/span><\/span><\/p>\n

Acknowledging the Patient’s
\nDilemma<\/strong><\/span>
\n<\/span><\/span><\/p>\n

If the patient cannot or is unwilling to disclose suspected
\n<\/sup>battering, or if she has disclosed such information but has
\n<\/sup>chosen not to leave the battering situation, the physician should
\n<\/sup>let her know that he or she will nonetheless remain available
\n<\/sup>to offer assistance and support. Phrases such as “You did not
\n<\/sup>deserve to be hit or hurt, no matter what happened”; “I am concerned
\n<\/sup>for your safety, and for the safety of your children”; “In my
\n<\/sup>experience, the violence does not go away, it generally gets
\n<\/sup>worse over time”; and most importantly, “I am here to advocate
\n<\/sup>for you and help you get to safety whenever you are ready to <\/sup>do
\nso” can be intensely powerful therapeutic tools in the office
\n<\/sup>setting. <\/sup>
\n<\/span><\/span><\/p>\n

Focusing on the Patient’s Strengths<\/span><\/strong>
\n<\/span><\/span><\/p>\n

A focus on the woman’s strengths in adverse circumstances, such <\/sup>as
\nmanaging the household, raising children, and taking prescribed
\n<\/sup>medications regularly, can be a positive therapeutic strategy
\n<\/sup>in view of the pervasive sense of failure and shame with which
\n<\/sup>most battered women live. <\/sup>
\n<\/span><\/span><\/p>\n

Providing Medical Treatment<\/span><\/strong>
\n<\/span><\/span><\/p>\n

Although the physician plays an important role in the multidisciplinary
\n<\/sup>hospital, office, and community team caring for battered women,
\n<\/sup>he or she is the only one who can direct and provide immediate
\n<\/sup>and follow-up medical care. Patients who present to emergency
\n<\/sup>settings should be referred for subsequent longitudinal care <\/sup>to
\na primary care physician, preferably one who has training, <\/sup>expertise,
\nand sensitivity in caring for victims of intimate <\/sup>partner
\nviolence. <\/sup>
\n<\/span><\/span><\/p>\n

Reviewing Options<\/span><\/strong>
\n<\/span><\/span><\/p>\n

Facilitating Referral<\/strong><\/span>
\n<\/span><\/span><\/p>\n

The physician should review the options available to the patient
\n<\/sup>and make appropriate referrals. Just as in the care of patients
\n<\/sup>with cancer, the physician should provide the patient with
\ninformation <\/sup>on available options and resources, as well as support in
\nmaking <\/sup>informed decisions regarding her care. The battered woman
\nmay <\/sup>choose to return home to the abuser because she may not feel
\n<\/sup>ready or able to leave at the time of the encounter with the
\n<\/sup>physician. An emergency shelter (assuming available space) is
\n<\/sup>another option if the patient does not feel she can safely return
\n<\/sup>home. <\/sup>
\n<\/span><\/span><\/p>\n

So that optimal care is rendered and the burden on the physician
\n<\/sup>is minimized, each patient who is a victim of abuse should be
\n<\/sup>referred to a telephone hotline, a battered women’s advocate,
\n<\/sup>or a similar resource whenever possible. Battered women’s services,
\n<\/sup>usually originating from emergency shelters, are free, confidential,
\n<\/sup>expert, and empowering and can provide survivors of domestic
\n<\/sup>violence with vital follow-up care. <\/sup>
\n<\/span><\/span><\/p>\n

Cautionary Notes about Couples
\nCounseling<\/strong><\/span>
\n<\/span><\/span><\/p>\n

Couples counseling is contraindicated in cases of active domestic
\n<\/sup>violence [30]<\/a>.
\nAlthough practiced by some family therapists <\/sup>in cases in which the
\nlevel of violence is considered to be <\/sup>low [31]<\/a>,
\ncouples counseling should be avoided in the primary <\/sup>care
\nsetting. <\/sup>
\n<\/span><\/span><\/p>\n

Legal Referral<\/strong><\/span>
\n<\/span><\/span><\/p>\n

Many battered women can benefit from access to basic legal information
\n<\/sup>and assistance through referral to an attorney, court advocate,
\n<\/sup>or legal services center. The physician can serve a key role <\/sup>in
\nproviding telephone numbers and support for the patient in <\/sup>this
\nregard. <\/sup>
\n<\/span><\/span><\/p>\n

The Safety Plan<\/span><\/strong>
\n<\/span><\/span><\/p>\n

The most dangerous time for a battered woman is when she decides
\n<\/sup>to leave her abuser. Ensuring that the patient has an individualized
\n<\/sup>safety plan is therefore a crucial and potentially life-saving
\n<\/sup>step. Although it is the physician’s responsibility to make
\n<\/sup>sure a safety plan is developed if disclosure occurs in the
\n<\/sup>health care setting, the actual formulation of the safety plan
\n<\/sup>can be somewhat time-consuming and is best accomplished with
\n<\/sup>the assistance of a skilled social worker, nurse, or battered
\n<\/sup>women’s advocate. <\/sup>
\n<\/span><\/span><\/p>\n

The safety plan should include the following elements: emergency
\n<\/sup>procedures, home safety, an abuse prevention order, safety on
\n<\/sup>the job and in public, and logistical issues [32]<\/a>.
\n<\/sup>
\n<\/span><\/span><\/p>\n

Emergency Procedures<\/strong><\/span>
\n<\/span><\/span><\/p>\n

Emergency procedures should include a discussion about ways <\/sup>the
\npatient can attain safety during an explosive incident, <\/sup>such as which
\nrooms of the house to avoid (for example, the <\/sup>kitchen, where knives
\nare readily accessible, and the bedroom, <\/sup>where most firearms are
\nhidden and where most sexual assaults <\/sup>occur), how to exit rapidly and
\nsafely, and how to alert a neighbor <\/sup>to call the police if an
\naltercation is overheard or if a special <\/sup>code or signal is
\nreceived. <\/sup>
\n<\/span><\/span><\/p>\n

Home Safety<\/strong><\/span>
\n<\/span><\/span><\/p>\n

A discussion about the following issues should be included:
\n<\/sup>changing door locks, installing a caller identification system
\n<\/sup>on the telephone or having an unpublished telephone number, <\/sup>and
\nletting the children know not to unlock the door for anyone,
\n<\/sup>including the batterer. <\/sup>
\n<\/span><\/span><\/p>\n

Abuse Prevention Order<\/strong><\/span>
\n<\/span><\/span><\/p>\n

An abuse prevention order, known in some states as an order <\/sup>of
\nprotection or a restraining order, is a legal document issued <\/sup>by a
\ncourt of law, enforceable in most states by immediate arrest <\/sup>for
\nviolation. The order is designed to protect an individual <\/sup>from abuse,
\ninjury, or threat of injury by an intimate partner <\/sup>or relative. In
\ncases of domestic violence, the abuse prevention <\/sup>order should be
\ncarried on the victim’s person at all times, <\/sup>and a copy should be
\nkept in a secure location elsewhere. Neighbors <\/sup>should be alerted to
\nthe presence of such an order and instructed <\/sup>to contact the police if
\nthe batterer attempts to confront the <\/sup>victim or enter the victim’s
\nproperty. The police should be <\/sup>informed of the nature of the call if
\nthis occurs. <\/sup>
\n<\/span><\/span><\/p>\n

Workplace Safety<\/strong><\/span>
\n<\/span><\/span><\/p>\n

Because safety on the job is another important issue, the abuse
\n<\/sup>prevention order should be written to extend to the victim’s
\n<\/sup>work site, and coworkers, supervisors, and company security
\n<\/sup>should be alerted to its existence and provisions. <\/sup>
\n<\/span><\/span><\/p>\n

Logistical Considerations<\/strong><\/span>
\n<\/span><\/span><\/p>\n

Discussion regarding a place to which the victim can go that <\/sup>is
\nunknown to the batterer, how to get there, and essentials <\/sup>to have
\npacked (such as money, keys, medications, insurance <\/sup>and other cards,
\nand changes of clothes for the woman and her <\/sup>children) should be
\nincluded as part of the safety plan. <\/sup>
\n<\/span><\/span><\/p>\n

<\/a><\/p>\n\n\n\n
Primary and Secondary
\n Prevention in the Office Setting <\/span><\/p>\n\n\n\n
<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<\/th>\n<\/tr>\n<\/tbody>\n<\/table>\n

Many
\nways are available to bring effective primary and secondary
\n<\/sup>prevention into the office practice setting. First, clinical
\n<\/sup>office staff should receive periodic training on the basic dynamics
\n<\/sup>of the abusive relationship, as well as in office screening,
\n<\/sup>triage, and referral. Second, the office receptionist should <\/sup>be
\nprovided with telephone numbers of local resources that can <\/sup>be given
\nto patients on request. Third, ancillary staff such <\/sup>as clerks,
\nparking lot attendants, and security personnel should <\/sup>be trained, as
\nappropriate to their position and skill, in basic <\/sup>domestic violence
\nawareness and response. Suspicious situations, <\/sup>such as yelling,
\npushing, slapping, or other inappropriate behavior <\/sup>in the parking lot
\nor waiting area, should then be reported <\/sup>confidentially to the
\nphysician or nurse. Fourth, posters, pamphlets, <\/sup>and other patient
\neducation material should be available in <\/sup>the office reception area
\nand in private locations such as bathrooms <\/sup>and examination rooms.
\nFifth, the physician should invite a <\/sup>discussion with the patient
\nabout nonviolent alternatives for <\/sup>the resolution of conflict in the
\nhome. These issues should <\/sup>be discussed with male and female patients
\nand can be an important <\/sup>component of creating an atmosphere of
\nprimary prevention-oriented <\/sup>health advocacy for all patients.
\n<\/sup>
\n<\/span><\/span><\/p>\n

A strong, consistent, and integrated message that the physician
\n<\/sup>and office staff are knowledgeable and concerned about domestic
\n<\/sup>violence can create a physician-patient atmosphere that
\ncomprehensively <\/sup>yet efficiently addresses the issues at hand while
\nrespecting <\/sup>the time demands placed on the practicing physician.
\n<\/sup>
\n<\/span><\/span><\/p>\n

<\/a><\/p>\n\n\n\n
Working Effectively
\n with Victims of Abuse while Recognizing the Barriers That Physicians Face
\n <\/span><\/p>\n\n\n\n
<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<\/th>\n<\/tr>\n<\/tbody>\n<\/table>\n

Physicians
\nface many attitudinal and logistical obstacles in <\/sup>approaching the
\ncare of battered women [1,33]<\/a>.
\nSugg and Inui <\/sup>[1]<\/a>
\ndetermined that the imagery of “opening Pandora’s box” was <\/sup>a common
\nreaction of physicians to the prospect of exploring <\/sup>issues of
\ndomestic violence with patients. Although these barriers <\/sup>can
\nsubstantially affect the physician’s responsiveness to this <\/sup>problem,
\nthey should not pose insurmountable obstacles to working <\/sup>effectively
\nin the care of battered patients. The following <\/sup>are barriers that
\nphysicians face and their possible solutions. <\/sup>
\n<\/span><\/span><\/p>\n

The Fantasy of the Perfect Family<\/span><\/strong>
\n<\/span><\/span><\/p>\n

Many physicians who themselves have not experienced domestic
\n<\/sup>violence adhere to an idealized vision of the home and have
\n<\/sup>expressed difficulty approaching screening for domestic violence
\n<\/sup>in patients who come from socioeconomic and demographic backgrounds
\n<\/sup>similar to theirs. It is often difficult to acknowledge the
\n<\/sup>possibility of abuse in persons who are so much “like us” because
\n<\/sup>compassionate care requires an empathic response in the physician.
\n<\/sup>Recognition, through education and clinical experience, of the
\n<\/sup>prevalence and spectrum of abuse in different sociodemographic
\n<\/sup>groups can enable the physician to work more effectively and
\n<\/sup>empathically. <\/sup>
\n<\/span><\/span><\/p>\n

The Reality of the Imperfect Patient<\/span><\/strong>
\n<\/span><\/span><\/p>\n

Many battered women do not present to the health care setting <\/sup>as
\n“model” patients. The relatively high prevalence of psychological <\/sup>and
\nsomatic sequelae of abuse (such as chronic pain symptoms, <\/sup>depression,
\nand alcoholism and other substance abuse), combined <\/sup>with frequent yet
\noften episodic use of health care services, <\/sup>serves to make many
\nbattered patients less desirable in medical <\/sup>venues than patients who
\npresent for regularly scheduled care <\/sup>on time, have one or a few
\nconcrete issues, and rapidly get <\/sup>better with prescribed treatment. In
\naddition, physicians, not <\/sup>unlike other members of society, are
\nsubject to stereotyped <\/sup>assumptions regarding domestic violence. The
\nfollowing are examples <\/sup>of such assumptions: Domestic violence is
\nrare; domestic violence <\/sup>may occur but is seen mostly in other
\nphysicians’ practices; <\/sup>intimate partner abuse does not occur in
\nfamilies that appear <\/sup>“normal”; battered women have brought on the
\nabuse because of <\/sup>their behavior in the relationship; and finally, if
\nbattered <\/sup>women don’t leave or if they subsequently return to the
\nabuser, <\/sup>the abuse was not very severe or a codependency within the
\nrelationship <\/sup>makes the woman seek the abuse. Such stereotyped
\nassumptions <\/sup>can only undermine the ability of the physician to
\nprovide optimal <\/sup>care. Recognition of the varied medical and
\nbehavioral sequelae <\/sup>of abuse can enable the physician to work more
\neffectively and <\/sup>empathically. Unbiased, data-supported educational
\ninitiatives <\/sup>combined with compassionate, non-judgmental attitudes can
\ndispel <\/sup>such value-laden myths. Educational initiatives must
\nencompass <\/sup>all phases of medical training and continuing medical
\neducation <\/sup>and should also include training for office staff.
\n<\/sup>
\n<\/span><\/span><\/p>\n

The Physician’s Previous Abuse<\/span><\/strong>
\n<\/span><\/span><\/p>\n

The physician may have been a victim of child physical or sexual
\n<\/sup>abuse or an adult victim, or perpetrator, of intimate violence.
\n<\/sup>In the study by Sugg and Inui [1]<\/a>,
\n14% of male physicians and <\/sup>31% of female physicians acknowledged a
\npersonal history of <\/sup>child abuse or of physical abuse as an adult. As
\nprofessional <\/sup>and personal supports become more available to
\nphysicians, their <\/sup>own histories and recovery from abuse can be better
\naddressed, <\/sup>thus enabling improved patient care. <\/sup>
\n<\/span><\/span><\/p>\n

Fear of Offending Patients<\/span><\/strong>
\n<\/span><\/span><\/p>\n

Some physicians are reluctant to ask their patients about abuse,
\n<\/sup>fearing they may offend patients by asking about a topic that
\n<\/sup>society considers a private matter, one that should stay “behind
\n<\/sup>closed doors.” Most patients are grateful to their physicians
\n<\/sup>who routinely inquire about violence and abuse in relationships
\n<\/sup>and do not consider this line of inquiry to be offensive or
\n<\/sup>intrusive. Addressing issues of violence and abuse is generally
\n<\/sup>welcomed by patients, who look to their physicians for advice
\n<\/sup>and support in areas in which the physician feels competent <\/sup>to
\nengage. <\/sup>
\n<\/span><\/span><\/p>\n

Powerlessness and Lack of Control<\/span><\/strong>
\n<\/span><\/span><\/p>\n

Physicians often feel overwhelmed by the size of the problem <\/sup>and
\nhelpless in their efforts to be effective in bringing about <\/sup>any type
\nof meaningful change in a battered patient’s life. <\/sup>In addition,
\nalthough willing to screen, identify, treat, and <\/sup>refer victims of
\nintimate partner abuse, many physicians are <\/sup>frustrated with their
\ninability to direct the outcome and with <\/sup>their patients’ inability to
\neffect meaningful changes in their <\/sup>life circumstances. The lack of
\neasily identifiable therapeutic <\/sup>tools, combined with the complex
\nmedical, social, and behavioral <\/sup>issues at play, usually make an easy
\ndiagnosis and quick fix <\/sup>untenable in instances of domestic violence.
\nThe ability of <\/sup>the physician to function as a member of a
\nmultidisciplinary <\/sup>team, use available community resources, and
\nunderstand that <\/sup>the most appropriate treatment should consider the
\npatient’s <\/sup>individual needs in the context of her own life
\ncircumstances <\/sup>is important in addressing the physician’s feelings of
\npowerlessness <\/sup>and lack of control. <\/sup>
\n<\/span><\/span><\/p>\n

Lack of Education<\/span><\/strong>
\n<\/span><\/span><\/p>\n

Most practicing physicians have received no education in domestic
\n<\/sup>violence during medical school, postgraduate training, or continuing
\n<\/sup>medical education. The lack of basic knowledge and skill in
\n<\/sup>this area is closely related to many of the other physician
\n<\/sup>barriers described above. Domestic violence is only now becoming
\n<\/sup>recognized as a problem that is appropriately addressed in the
\n<\/sup>health care setting and taught in educational venues. Core competency
\n<\/sup>in knowledge, skill, and attitudes in primary prevention and <\/sup>in
\ncaring for victims of intimate partner violence should be <\/sup>included in
\nundergraduate medical education and postgraduate <\/sup>training.
\nHigh-quality, skill-based continuing medical education <\/sup>programs
\nshould be available to physicians in practice and encouraged <\/sup>through
\nspecialty societies and organized medicine. <\/sup>
\n<\/span><\/span><\/p>\n

Fear of Precipitating More Violence<\/span><\/strong>
\n<\/span><\/span><\/p>\n

Given the known increase in danger to the victim when she decides
\n<\/sup>to leave an abusive relationship, some physicians are reluctant
\n<\/sup>to risk doing more harm by advocating on behalf of a battered
\n<\/sup>woman, empowering her to decide to leave, and thus potentially
\n<\/sup>precipitating nonlethal injury or even homicide. Safety planning
\n<\/sup>should be incorporated into the treatment strategy for every
\n<\/sup>current victim of domestic violence. Such safety planning is
\n<\/sup>best done with an expert in crisis intervention in domestic
\n<\/sup>violence, usually a battered women’s advocate. <\/sup>
\n<\/span><\/span><\/p>\n

The Tyranny of Time<\/span><\/strong>
\n<\/span><\/span><\/p>\n

Time constraints can be a formidable barrier to doing effective
\n<\/sup>work with battered patients. Many physicians feel they have
\n<\/sup>inadequate time to intervene effectively if a patient discloses
\n<\/sup>abuse. Others voice frustration that having to ask about “one
\n<\/sup>more thing” will be too burdensome in a clinical encounter that
\n<\/sup>is already full. Clearly, a crisis situation in domestic violence,
\n<\/sup>similar to a cardiac crisis or the exigencies of dealing with
\n<\/sup>an acutely suicidal patient, needs to be triaged appropriately
\n<\/sup>and expeditiously. Professional and community colleagues who
\n<\/sup>can be contacted rapidly, the availability and use of patient
\n<\/sup>education materials, and the implementation of updated office
\n<\/sup>protocols can minimize the disruption in office routine when <\/sup>a
\ndiagnosis of current domestic violence is established. In <\/sup>the setting
\nof routine patient care, questioning about violence <\/sup>in relationships
\ncan be easily incorporated into the periodic <\/sup>history and physical
\nexamination, along with a message of compassion, <\/sup>empathy, and concern
\nabout the issue. This simple message of <\/sup>care can have a tremendously
\npositive effect on the physician-patient <\/sup>relationship overall and may
\neven improve the flow and efficiency <\/sup>of patient care. <\/sup>
\n<\/span><\/span><\/p>\n

Isolation<\/span><\/strong>
\n<\/span><\/span><\/p>\n

Physicians who try to provide solo care for victims of domestic
\n<\/sup>violence are doing both themselves and their patients a disservice.
\n<\/sup>This work can be stressful, emotionally draining, and disturbing
\n<\/sup>and should not be under-taken in isolation. Physicians are encouraged
\n<\/sup>to develop a support network in the local community; to share
\n<\/sup>the burden of active cases; and to offer mutual supervision,
\n<\/sup>support, and collegiality. <\/sup>
\n<\/span><\/span><\/p>\n

Office Security and Personal Safety<\/span><\/strong>
\n<\/span><\/span><\/p>\n

Although not mentioned as a barrier by the physicians responding
\n<\/sup>in Sugg and Inui’s study [1]<\/a>,
\nother physicians have voiced reluctance <\/sup>to ask about or intervene in
\nsituations of domestic violence, <\/sup>out of concern for their own
\npersonal safety or that of their <\/sup>office staff. I know of no reports
\nof health care workers being <\/sup>threatened, injured, or killed by the
\npartners of patients who <\/sup>are victims of domestic violence. However,
\nthe potential risks <\/sup>to office staff must be considered in any
\npotentially volatile <\/sup>situation. The contract of care is between the
\nphysician and <\/sup>the patient. When the patient is a victim of domestic
\nabuse, <\/sup>the perpetrator should not be contacted or confronted in
\nthe <\/sup>office setting. In addition, training for office personnel
\non <\/sup>recognizing and responding to domestic violence issues, and
\n<\/sup>in assuring strict patient confidentiality, is encouraged. Emergency
\n<\/sup>procedures should be outlined and practiced in the office setting
\n<\/sup>for potential emergencies in domestic violence, as well as in
\n<\/sup>other situations. <\/sup>
\n<\/span><\/span><\/p>\n

<\/a><\/p>\n\n\n\n
Summary <\/span><\/p>\n\n\n\n
<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<\/th>\n<\/tr>\n<\/tbody>\n<\/table>\n\n\n\n
Top<\/span>
<\/a>Summary<\/span>
Author & Article Info<\/span>
<\/a>References<\/span>
<\/a><\/span><\/th>\n<\/tr>\n<\/tbody>\n<\/table>\n

In
\nconclusion, the short- and long-term effects of domestic <\/sup>violence are
\nhealth care issues that nearly every practicing <\/sup>physician encounters
\nin the course of routine clinical practice. <\/sup>Physicians are now
\nexpected to know the basics of recognition <\/sup>and intervention related
\nto primary prevention, early intervention, <\/sup>and crisis care of victims
\nof domestic violence. The importance <\/sup>of routinely integrating
\nquestioning about violent conflict <\/sup>and intervention into office
\npractice, particularly in generalist <\/sup>fields such as internal
\nmedicine, are important components of <\/sup>the new agenda for health care
\nin the twenty-first century. <\/sup>
\n<\/span><\/span><\/p>\n

Requests for Reprints: Elaine J. Alpert, MD, Boston University
\n<\/sup>School of Medicine, 80 East Concord Street, Boston, MA 02118-2394.
\n<\/sup>
\n<\/span><\/span><\/p>\n

<\/a><\/p>\n\n\n\n
Author and Article
\n Information <\/span><\/p>\n\n\n\n
<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<\/th>\n<\/tr>\n<\/tbody>\n<\/table>\n\n\n\n
Top<\/span>
<\/a>Summary<\/span>
<\/a>Author & Article Info<\/span>
References<\/span>
<\/a><\/span><\/th>\n<\/tr>\n<\/tbody>\n<\/table>\n

<\/a>From Boston University
\nSchool of Medicine, Boston, Massachusetts. For the current author address, see
\nend of text. <\/span>
\n<\/span><\/span><\/p>\n

<\/a><\/p>\n\n\n\n
References <\/span><\/p>\n\n\n\n
<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<\/th>\n<\/tr>\n<\/tbody>\n<\/table>\n\n\n\n
Top<\/span>
<\/a>Summary<\/span>
<\/a>Author & Article Info<\/span>
<\/a>References<\/span>
<\/span><\/th>\n<\/tr>\n<\/tbody>\n<\/table>\n

<\/a>
\n<\/span><\/span><\/p>\n

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\n<\/span><\/span><\/p>\n

2.<\/strong> Education about adult domestic violence in U.S. and Canadian
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\n<\/span><\/span><\/p>\n

3.<\/strong> Hendricks-Matthews MK. A survey on violence education: a report of
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\n<\/span><\/span><\/p>\n

4.<\/strong> Alpert EJ. Report of the committee on violence. Waltham, MA:
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\n<\/span><\/span><\/p>\n

5.<\/strong> Alpert EJ, Freund KM, Park CC, Patel JC, Sovak MA. Partner
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\n<\/span><\/span><\/p>\n

6.<\/strong> Bachman R. U.S. Department of Justice, Bureau of Justice
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\n<\/span><\/span><\/p>\n

7.<\/strong> Califia P. The hidden problem of gay domestic violence. The
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\n<\/span><\/span><\/p>\n

8.<\/strong> Lobel K, ed. Naming the Violence. Speaking Out about Lesbian
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\n<\/span><\/span><\/p>\n

10.<\/strong> McCauley J, Kern DE, Kolodner K, Dill L, Schroeder AF, DeChant HK,
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\n<\/span><\/span><\/p>\n

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\n<\/span><\/span><\/p>\n

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\n<\/span><\/span><\/p>\n

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15.<\/strong> Harrop-Griffiths J, Katon W, Walker E, Holm L, Russo J, Hickok L.
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16.<\/strong> Herman JL. Trauma and Recovery. New York: Basic Books; 1992.<\/a>
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17.<\/strong> Amaro H. Violence during pregnancy and substance use. Am J Public
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\n<\/span><\/span><\/p>\n

18.<\/strong> Parker B, McFarlane J, Soeken K, Torres S, Campbell D. Physical
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\n<\/span><\/span><\/p>\n

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\n<\/span><\/span><\/p>\n

23.<\/strong> Physicians and domestic violence. Ethical considerations. Council
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\n<\/span><\/span><\/p>\n

24.<\/strong> Rath GD, Jarratt LG. Battered wife syndrome: overview and
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\n<\/span><\/span><\/p>\n

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\n<\/span><\/span><\/p>\n

27.<\/strong> McLeer SV, Anwar R. A study of battered women presenting in an
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\n<\/span><\/span><\/p>\n

28.<\/strong> Groves BM, Zuckerman B, Marans S, Cohen D. Silent victims:
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\n<\/span><\/span><\/p>\n

29.<\/strong> American Medical Association. Council on Ethical and Judicial
\nAffairs. Opinion 5.05: confidentiality. Current Opinions of the Council on
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\n<\/span><\/span><\/p>\n

30.<\/strong> Bograd M. Family systems approaches to wife battering: a feminist
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\n<\/span><\/span><\/p>\n

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\n1995:501-18.<\/a>
\n<\/span><\/span><\/p>\n

32.<\/strong> Cambridge, Massachusetts Police Department. What you should know
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\n<\/span><\/span><\/p>\n

33.<\/strong> King MC, Ryan J. Abused women: dispelling myths and encouraging
\nintervention. Nurse Pract. 1989;14:47-58.<\/span>
\n<\/span>
<\/a>\n<\/p>\n

This article has been cited by other
\narticles:<\/strong><\/span>\n<\/p>\n\n\n\n\n
<\/td>\n<\/td>\n\"Home<\/a><\/td>\n<\/td>\n\"Arch\"Home<\/a>
N. K. Sugg, R.
\n S. Thompson, D. C. Thompson, R. Maiuro, and F. P.
\n Rivara
Domestic Violence and Primary Care: Attitudes,
\n Practices, and Beliefs<\/strong>
Arch Fam Med, July 1, 1999;
\n 8(4): 301 – 306.
[Abstract]<\/a>
\n [Full
\n Text]<\/a> [PDF]<\/a>
\n
<\/span><\/td>\n		<\/td>\n<\/tr>\n
\n
\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n\n\n\n\n
<\/td>\n<\/td>\n\"Home<\/a><\/td>\n<\/td>\n\"BMJ\"\"Home<\/a>
F. Bradley, M.
\n Smith, J. Long, and T. O’Dowd
Reported frequency of domestic
\n violence: cross sectional survey of women attending general
\n practice<\/strong>
BMJ, February 2, 2002; 324(7332): 271 –
\n 271.
[Abstract]<\/a>
\n [Full
\n Text]<\/a> [PDF]<\/a>
\n
<\/span><\/td>\n		<\/td>\n<\/tr>\n
\n
\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n\n\n\n\n
<\/td>\n<\/td>\n\"Home<\/a><\/td>\n<\/td>\n\"Am.\"Home<\/a>
K. K.
\n Danielson, T. E. Moffitt, A. Caspi, and P. A. Silva
Comorbidity
\n Between Abuse of an Adult and DSM-III-R Mental Disorders: Evidence From an
\n Epidemiological Study<\/strong>
Am. J. Psychiatry,
\n January 1, 1998; 155(1): 131 – 133.
[Abstract]<\/a>
\n [Full
\n Text]<\/a>
<\/span><\/td>\n		<\/td>\n<\/tr>\n
\n
\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n\n\n\n\n
<\/td>\n<\/td>\n\"Home<\/a><\/td>\n<\/td>\n\"eWJM\"\"Home<\/a>
B. Gerbert, J.
\n Moe, N. Caspers, P. Salber, M. Feldman, K. Herzig, and A.
\n Bronstone
Simplifying physicians’ response to domestic
\n violence<\/strong>
West J Med, May 1, 2000; 172(5): 329 – 331.
\n
[Full
\n Text]<\/a>
<\/span><\/td>\n		<\/td>\n<\/tr>\n
\n
\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

<\/a>\n<\/p>\n

Related
\narticles in Annals:<\/span><\/strong>\n<\/p>\n

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<\/span><\/dd>\n

Reviews
Sexual and Physical Abuse and Gastrointestinal Illness:
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\n <\/span><\/dt>\n
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\n and Marcelo A. Barreiro
Annals 1995 123: 782-794. (in ) [Abstract]<\/a>
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Editorials
From Public Health to Personal Health: Violence
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Annals 1995 123: 800-802. (in ) [Full
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<\/span><\/dl>\n

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\nAmerican College of Physicians.<\/a><\/span><\/span><\/div>\n","protected":false},"excerpt":{"rendered":"

Search Annals: Advanced search  Home | Current Issue | Past Issues | Search | Collections | Subscribe | Contact Us | Help | ACP Online             Article    Table of Contents                    Abstract of this article    Figures\/Tables List    Related articles in Annals    Articles citing this article  Services    Notify a friend….<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":1518,"menu_order":0,"comment_status":"open","ping_status":"open","template":"","meta":{"_bbp_topic_count":0,"_bbp_reply_count":0,"_bbp_total_topic_count":0,"_bbp_total_reply_count":0,"_bbp_voice_count":0,"_bbp_anonymous_reply_count":0,"_bbp_topic_count_hidden":0,"_bbp_reply_count_hidden":0,"_bbp_forum_subforum_count":0,"footnotes":""},"class_list":["post-1521","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/jacobimed.org\/old\/wp-json\/wp\/v2\/pages\/1521","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/jacobimed.org\/old\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/jacobimed.org\/old\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/jacobimed.org\/old\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/jacobimed.org\/old\/wp-json\/wp\/v2\/comments?post=1521"}],"version-history":[{"count":1,"href":"https:\/\/jacobimed.org\/old\/wp-json\/wp\/v2\/pages\/1521\/revisions"}],"predecessor-version":[{"id":1522,"href":"https:\/\/jacobimed.org\/old\/wp-json\/wp\/v2\/pages\/1521\/revisions\/1522"}],"up":[{"embeddable":true,"href":"https:\/\/jacobimed.org\/old\/wp-json\/wp\/v2\/pages\/1518"}],"wp:attachment":[{"href":"https:\/\/jacobimed.org\/old\/wp-json\/wp\/v2\/media?parent=1521"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}