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Asking right questions key to detecting abuse

Less obvious red flags include chronic pain, anxiety

From the March ACP Internist, copyright © 2009 by the American College of Physicians

By Jessica Berthold

Years after the fact, David Schneider, MD, still remembers a patient whose odd behavior troubled him. The Vietnamese woman always came to her primary care appointments with her husband, and looked to him for approval every time she spoke. The doctor suspected she might be abused-but he couldn't ask discreetly because her husband was serving as her translator.

Dr. Schneider, professor and chair of family medicine at St. Louis University, wasn't able to confirm his hunch because the patient never returned. Were it correct, however, he wouldn't have been surprised: About 5%-7% of women who walk through the door of a primary care office are physically abused by a partner. These women are more prone to chronic pain, physical injury, mental illness and treatment non-adherence, but their situation often goes undetected by internists.

Asking right questions key to detecting abuse

"Studies tell us about one in 10 physicians asks their patients about this," said Therese Zink, MD, family medicine professor at the University of Minnesota. "People get educated about it in medical school, but then they go out and work with practicing doctors who aren't modeling how to ask."

While intimate partner violence (IPV) occurs among people of all races, ethnicities, ages, and socioeconomic levels, research consistently shows a higher risk for women, with a lifetime prevalence of around 25% compared with about 8% for men, according to the 2000 National Violence Against Women survey, co-sponsored by the CDC and National Institute of Justice. Women are also more likely to suffer serious injuries when they are abused. As such, an internist's radar should always be attuned to the possibility of IPV, especially in female patients, and the doctor should know how to respond, experts said.

Warning signs

It's clear an internist should ask about IPV if a patient presents with suspicious symptoms, like unexplained bruising or injuries. But there are less obvious symptoms that also should raise a red flag, like chronic pain, depression and anxiety, experts said.

"Chronic pain syndromes are notorious for having a high correlation with abusive experiences. This includes chronic low back, abdominal or pelvic pain, headaches and TMJ (temporomandibular joint disorder)," said Arlene Bradley, FACP, the College's representative to the American Medical Association's National Advisory Council on Violence and Abuse.

Mental illnesses like depression, anxiety, post-traumatic stress disorder, substance abuse and suicide have also been associated with IPV, experts said. In addition, people with personality disorders have an 80%-95% chance of having been abused in childhood, which predisposes them to abuse in adulthood as well, Dr. Bradley said.

Patients who come to the office with vague, unexplained physical symptoms such as insomnia or lack of energy should also be asked about domestic violence, especially if they return repeatedly, said Christina Nicolaidis, MD, associate professor of medicine and public health at Oregon Health & Science University.

"In this case, it is really important to make sure the patient knows we aren't asking (about IPV) to discount her symptoms. The fear from people is that, if they tell you about pain and you ask about violence, it means you think it's all in their head," Dr. Nicolaidis said. "Make it clear you believe the patient's symptoms, and explain that violence can make symptoms more severe and harder to treat."

Noncompliance with treatment can be a warning sign, too; abusing partners have been known to prevent patients from getting care. In a study in the June 28, 2007 online issue of the Journal of General Internal Medicine, 5% of female outpatients reported that their partners interfered with their care.

Dr. Nicolaidis had one patient who presented to the hospital a full two days after having a large myocardial infarction because her partner discouraged her from seeking help. The partner of a different patient, who had diabetes, would regularly "punish" her by taking her insulin away, and thus the diabetes was poorly controlled, Dr. Nicolaidis said.

Patients who have extreme negative reactions to things like pelvic exams or informed-consent procedures may also have some current or past experience with intimate partner violence that needs to be explored, said Jane Liebschutz, FACP, associate professor of medicine at Boston University Medical Center and author of "Violence Against Women: A Physician's Guide to Identification and Management," published by ACP Press.

"If a patient was abused while drugged or asleep, she may fear a conscious sedation procedure because of the loss of control," Dr. Liebschutz said.

As with Dr. Schneider's Vietnamese patient, a physician can sometimes sense a problem by observing the patient and partner interact. The partner may do all the talking or interrupt the patient, or the patient may repeatedly look to her partner for approval after speaking.

"In this situation, you do your best to separate them, usually by telling the partner that he needs to leave per clinic policy," Dr. Schneider said. "If he won't leave, you tell the patient you can't examine her until her partner leaves."

A change in power balance between couples can also trigger domestic violence, Dr. Zink said. This balance might change if someone becomes ill, or if there is a change in one partner's mental health status. Research also shows a higher risk for certain categories of women, said Amy S. Gottlieb, MD, assistant professor of medicine and obstetrics and gynecology (clinical) at Brown University Medical School.

"Women who are unmarried, have low income, are uninsured or on medical assistance, and have a history of childhood maltreatment are more at risk," Dr. Gottlieb said. "During and right after pregnancy is also a high-risk time. One possible reason is that there may be jealousy about the mother's change of focus."

When and how to ask

In addition to asking when a patient presents with a warning sign, many experts think it's prudent to routinely ask patients about IPV during new patient interviews and annual visits. The issue is controversial, however. In 2004, the U.S. Preventive Services Task Force stated there was insufficient evidence to recommend asymptomatic patients be screened for domestic violence, but the American Medical Association quickly countered by saying health care providers should continue screening those patients.

IPV is not like hypertension, where a simple test can reveal a problem, Dr. Nicolaidis noted. It can take years for a patient to disclose that he or she is a victim, and even more time for the patient to take steps to improve her situation.

"We don't consider it a screening test to ask people where they live and if they are homeless; this is just basic information that affects their health and will help you, for example, manage their diabetes. Likewise, asking about IPV is part of a complete history and affects how you will take care of your patient's problems," Dr. Nicolaidis said.

Research shows the chances of disclosure are better if a patient is asked specific questions about abuse. A general question, like whether a person feels safe at home, is not very helpful, Dr. Nicolaidis said.

"General questions don't teach anything, and they don't get people thinking," Dr. Nicolaidis said. "You have to be very specific."

Still, some physicians like to warm up to the topic by asking a patient about who she lives with, what sort of relationship she's in and how it's going, then moving on to more specific questions.

"Based on the responses to the first questions, I might ask more detailed questions, like 'Are you being hurt; have you been hurt in past relationships', and then get more concrete by asking if the person has been hit, slapped, shoved around or physically hurt in other ways," Dr. Bradley said.

One should ask about emotional abuse as well, Dr. Nicolaidis said, including whether the patient currently feels like she is controlled or threatened, or her partner is particularly jealous. This kind of abuse is damaging on its own, and can eventually lead to physical abuse.

Placing posters and educational material in the waiting rooms, exam rooms and bathrooms can also encourage patients to open up, Dr. Liebschutz said.

If you suspect a patient is a victim of IPV but she denies it, try to ask about it in a few different ways, Dr. Schneider suggested.

"If the patient still denies it, you can just tell her that this is a place where she can talk about it, if it ever does happen. Then broach the subject again on a return visit," Dr. Schneider said.

A long process

Dr. Nicolaidis had known for years a female patient in her 70s who was in an abusive marriage. At every visit, the doctor would ask about the violence as she was managing the patient's chronic medical problems. The violence became part of the problem list, she said, just like the patient's pulmonary and heart disease.

"When her husband's alcoholism got worse and it was finally time for her to leave, she already had a safety plan in place because we had talked about it," Dr. Nicolaidis said. "If we hadn't had that relationship in place, this could have been a dangerous time."

Dr. Bradley likens domestic violence to smoking cessation, in terms of the physician's approach and the patients' timing. Patients probably won't stop smoking or make changes right away, but with repeated support and understanding from their physician, they are more likely to do so. This can be challenging for internists to accept, as can the idea that leaving an abusive partner isn't always the best solution for the patient, experts said.

"Physicians can have this unrealistic expectation that they will screen and get disclosures right away, then give the patient a referral card, and the patient will come back and say, 'Thank you, my life is all better,'" Dr. Nicolaidis said. "I've had a lot of patients who made really important changes in their lives, but it didn't happen right away."

She's disclosed: Now what?

Once a patient has disclosed IPV, the first step is to acknowledge the strength it took to disclose, and provide empathy-both of which are very important validations of the patient's experience, Dr. Liebschutz said. Next, the physician should get a safety assessment. This means asking whether there are guns in the house, whether the partner has ever threatened to kill her, and whether the partner abuses substances-all of which are warning signs of a high-risk situation.

Jacquelyn Campbell, PhD, RN, a professor at Johns Hopkins University, developed a one-page "danger assessment" tool which providers can use to assess a patient's risk for being a victim of homicide at the hands of her domestic partner. It's available online in English, Spanish, Portuguese and French.

In cases where a patient is in imminent danger, you need to "push hard" to get the person out of the situation, Dr. Schneider said. Make sure you have the names and phone numbers of local agencies that can help. In situations with low-level violence, internists shouldn't necessarily push for the patient to leave her partner, because the patient may simply stop coming to see you, Dr. Zink said.

"I had a patient in her early 20s come in for a well child exam; her child was about two months old. She told me she had gotten hit a few times, but this was her second kid, so she wasn't going to do anything right away to leave," Dr. Zink said. "I had to soft-pedal it and just let her know the door was open if she wanted help."

Sometimes Dr. Zink will call an advocacy agency and put the patient on the phone with the agency, so she can hear for herself what kind of support services there are, she said. For others unwilling to do that, she'll send them home with a pamphlet and make a follow-up appointment in two weeks.

If willing to take the time, a provider can help a patient make a plan to escape a dangerous situation, should the need arise, Dr. Schneider said.

"I'll help them figure out a place to put a little suitcase with clothes, cash, important papers, and a copy of their driver's license and social security card, so that if they are ready to leave and need to do so quickly, they have a plan," Dr. Schneider said. "If they have kids, we'll also make a plan to get the kids out safely."

After assessing the patient's safety, providers should document everything, so the patient has a legal record and so future providers are up to speed, experts said.

A helpful mnemonic for busy internists, developed by the Massachusetts Medical Society, is RADAR: Routinely ask about IPV; ask directly; document findings; assess safety; review options and refer, Dr. Gottlieb said.

All this may seem like a lot of work, but research shows it takes less time than one might suspect: 10 seconds if the answer about IPV is no; two minutes if the answer is yes but the abuse occurred in the distant past; and 12 minutes if the answer is yes and the abuse is current, Dr. Schneider said.

"Is 10 minutes worth saving a life? If that patient came in with chest pain, would you choose not to explore it?" Dr. Schneider said.

Besides, internists can shorten the protocol if they want to, said Pamela Charney, FACP, clinical professor of medicine at Albert Einstein College of Medicine.

"The internist should at least ask someone if the violence is happening right now and if they are safe leaving the office, and then give information on resources like 800 numbers or local shelters," Dr. Charney said.

"Just creating a place where the patient is treated respectfully can help break the cycle of violence."

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Additional resources about intimate partner violence

National Domestic Violence Hotline
Hotline for victims of abuse which provides crisis intervention, safety planning, information and referrals to agencies. 1-800-799-SAFE (7233)

National Coalition Against Domestic Violence
Provides information for victims on things like safety planning and attaining financial independence.

Danger Assessment Tool
Assesses a patient's risk for being a victim of homicide at the hands of a domestic partner.

Family Violence Prevention Fund
Wide-ranging site with information on abuse and its prevention, and how to deal with abuse victims in healthcare settings.

Domestic Violence Action Center
Provides legal information and representation to victims.

Violence Against Women: A Physician's Guide to Identification and Management
By Liebschutz, Frayne and Saxe. Published by ACP Press, 2003.

American Academy for Violence and Abuse
National group of health professionals who advocate for awareness of intimate partner violence in medical school, residency and beyond.

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