Tips for detecting—and treating—domestic abuse
By asking the right questions and using some simple strategies, residents can do a better job
From the February 1998 ACP Observer, copyright © 1998 by the American College of Physicians.
By Christine Wiebe
Marilynn's history of domestic abuse spans more than a decade and three husbands. Her first husband once beat her so badly she was sure he had broken her ribs, but she never sought medical help. When Marilynn had her first baby, her obstetrician seemed to recognize that she was depressed, but he never asked about her home life. If he had, Marilynn said, she probably would have told him about the abuse.
Throughout the years, Marilynn has had numerous encounters with physicians, all of whom, she said, seemed "disinterested" in her life. She struggled with being overweight, and more than one physician prescribed diet pills without even bothering to conduct a thorough checkup. "I wanted someone quite desperately to talk to," she said, but still she never mentioned her problems.
Finally, after her third husband died, Marilynn saw an internist because of chronic stomach pain, high blood pressure and continuing weight problems. The internist ran tests for ulcers and other likely causes but found no medical basis for her distress. "Then he asked me what was going on in my life," she recalled.
"It wasn't easy at first," she admitted, "but I needed someone to talk to who would understand." Finally, Marilynn's story began spilling out.
Aided by the additional information in her history, the internist diagnosed Marilynn with irritable bowel syndrome, which can be provoked by stress. In addition to treating her medically, he referred her to the local agency that shelters and counsels abused women. She joined a regular support group there.
Today, after considerable effort, Marilynn's depression is under control, her self-esteem is stronger, she has lost nearly 40 pounds and her health is significantly better. She credits her internist with helping her turn her life around. "He goes beyond just the medical issues," she said.
While experts say that more doctors could similarly help more of their own patients who are victims of domestic abuse, many physicians—including residents—simply find talking about domestic abuse difficult. "We feel uncomfortable asking about domestic violence the same way we are uncomfortable asking about sexual histories," said Adrienne Green, MD, chief resident at Stanford Health Services in Palo Alto, Calif. "It's much easier to ask people about hypertension and diabetes."
But statistics show that domestic abuse can be just as pervasive as clinical disease. Studies have concluded that about one in four adult women in the United States will be victimized by abuse at some point in their lives, said Elaine J. Alpert, ACP Member, assistant professor of public health and medicine at Boston University school of Medicine. In internal medicine clinics, about 15% of women are current or recent victims of abuse, she said. "And yet," Dr. Alpert added, "in primary care practices, domestic violence is almost never diagnosed."
"The magnitude of this problem cannot be ignored," said Sandra Adamson Fryhofer, FACP, an Atlanta internist who serves as ACP's Liaison for Women's Health. "As primary care physicians, we can intervene and break the cycle of domestic violence. But in order to do this, we must not only be armed with the right tools and information, but also take the time to ask the right questions."
'Who did this?'
Experts say that the screening process, however, is the point at which many domestic abuse victims fall through the cracks. Many doctors simply do not ask about domestic violence, even when they take patient histories or see obvious signs of abuse.
"Time after time I sign charts from residents that say the patient was punched in the face, and they never asked, 'Who did this?' " explained Kim Feldhaus, MD, associate program director at the University of Colorado Health Sciences Center in Denver.
Residents strapped for time and short on experience say they need help in knowing what to ask. "The hardest part in residency is developing the questions that you need to ask almost anybody," said Allen Friedland, ACP Associate, chief resident at the University of Cincinnati Medical Center.
Experts like Dr. Feldhaus say that screening for domestic violence can be a short and effective process. Working with colleagues at the University of Colorado, she developed a three-question tool called the Partner Violence Screen and tested it on 322 women at two emergency departments.
(Research results were reported in the May 7, 1997, issue of the Journal of the American Medical Association.) The tool has physicians ask the following questions:
- Have you been hit, kicked, punched or otherwise hurt by someone within the past year? If so, by whom?
- Do you feel safe in your current relationship?
- Is there a partner from a previous relationship who is making you feel unsafe now?
Researchers found that the tool could be administered in only 20 seconds—that's faster than taking a patient's vital signs—and that it detected about two-thirds of the domestic abuse victims that more complex assessments identify.
Dr. Feldhaus admitted that the tool isn't perfect; some domestic violence victims scored negative on all three questions. Nonetheless, she said that the ability to catch so many domestic violence cases using such a short, simple interview makes it a practical tool.
A curriculum developed by Dr. Alpert developed for the Massachusetts Medical Society can also teach residents to be more sensitive to signs of domestic abuse. The curriculum features a five-step model known as
"RADAR." The acronym stands for:
- R —Remember to ask about violence and victimization.
- A —Ask directly, "At any time or in the last year, have you been hit, hurt, threatened or frightened by someone with whom you are in a relationship?"
- D —Document findings in the medical records for the patient's legal protection.
- A —Assess the patient's immediate safety.
- R —Review options and refer (for example, crisis center, women's shelter) as appropriate.
In addition to asking the right questions, residents need to learn to deal with domestic abuse victims sensitively. "It's important to learn how to ask questions in a manner that's supportive and sensitive while maintaining patient confidentiality and keeping focused on the battered victim's safety and needs," said Dr. Alpert.
Although experts agree physicians should be direct when questioning domestic abuse victims, they also need to be diplomatic and non-judgmental. "You can only meet people half way," explained Susan Hadley, MPH, director of Minneapolis-based WomanKind, a domestic violence treatment program that has served as a model for other programs across the country. "If patients are not in a position to disclose, they're in a better position to know that than you."
In fact, physicians need to be careful not to replicate the abuse that victims suffer at home by insisting on a particular response, such as a commitment to leaving an abusive relationship. "Physicians should not be telling their patients what they should do, but rather letting them know what their options are and supporting them as they make choices," said Dr. Alpert.
When trying to help victims of domestic abuse, experts suggest the following:
- Establish a safe environment to interview the victim privately and assure her confidentiality.
- Validate the victim's feelings and reassure her that she does not deserve to be abused.
- Document any injuries, even if the patient denies abuse has occurred. In the patient's chart, use descriptive rather than subjective terms and draw a body map to record injuries. When possible, include direct quotes from the patient and photographs of the injuries.
- Make appropriate referrals to local shelters or counselors.
- Discuss a safety plan, including emergency phone numbers, particularly if the patient chooses not to leave a dangerous situation. Make a follow-up appointment if appropriate.
- Let the patient take control. Avoid replicating the abuse cycle by imposing your own opinions on the patient.
Direct screening followed by non-judgmental interventions can make dramatic differences in patients' lives, agrees former victim Marilynn. "Doctors should sit down and say, 'Let's have a person-to-person talk,' " she said. "I think they sometimes have to take the first step because a lot of women want to just keep hiding it."
Christine Wiebe of Providence, Utah, writes frequently on issues related to medical residency.
For more information
- The National Domestic Violence Hotline provides crisis assistance and local referrals. Information: 800-799-7233; the TDD line for the hearing impaired is 800-787-3224.
- The Massachusetts Medical Society's new curriculum, available for $450, includes a facilitator's text, a video, a three-disk CD-ROM and pocket guides. Information: 800-322-2303.
- The AMA's "Diagnostic and Treatment Guidelines on Domestic Violence" and "Diagnostic and Treatment Guidelines on Mental Health Effects of Family Violence" are available for $3 each ($2.25 for AMA members). Information: Mary Haynes, 312-464-5563.
- "Domestic Violence: A Guide for Health Care Providers" from the Colorado Coalition Against Domestic Violence gives an overview of domestic violence, provides tips for treating victims and suggests ways to develop policies and procedures. Information: 303-831-9632.
- "Violence in Intimate Relationships and the Practicing Internist: New 'Disease' or New Agenda?" takes a comprehensive look at internists' role in treating domestic violence; it was written by Elaine Alpert, ACP Member, and appears in Annals of Internal Medicine, Nov. 15, 1995, pp. 774-781.
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