Just Ask

Amber Cadick, PhD, HSPP

A 24-year-old male presents to your office with complaints of fatigue and pain. When you go to listen to his heart you notice some red marks on his chest. When inquiring about this he breaks down crying and unbuttons his shirt to reveal claw marks across his torso. He quietly confesses through sobs that his girlfriend has been physically abusing him for some time, and he doesn’t know how to exit the relationship.

During didactics you notice that one of your star residents is sleeping. She has moved her typical seat with her peers to alone on the side of the room. The next 3 weeks you notice her dozing often during the lectures. What should you attribute this to—laziness, fatigue, apathy? Other faculty have noticed, and some are thinking about talking to her concerning professionalism. Thinking back, you realize that she has been lingering by your office but not saying much. One day she comes into your office, closes the door, and begins to cry. She shares that she hasn’t been able to sleep at night due to a fear for her safety. She thought this change in her partner’s behavior would be temporary, but now she doesn’t know how to stop it. She feels trapped, isolated, and lonely. She notes it is hard to perform her job as a resident with this stress at home.

We all have our stereotypes of who is a victim of domestic violence, but I invite you to be mindful of this cognitive bias and consider the reality. While women are more likely than men to be injured and assaulted by their partners, men can also be on the receiving end of violence. In addition, patients and colleagues in professional roles may silently suffer with horror at home.

According to the American Academy of Family Physicians, there is no harm in screening for intimate partner violence. ¹ The Partner Violence Screen is a quick tool that is up to 71% sensitive and up to 94% specific for positively identifying victims of intimate partner violence. A positive response to any of the following denotes abuse.

1. Have you been hit, kicked, punched, or otherwise hurt by someone within the past year? If so, by whom?
2. Do you feel safe in your current relationship?
3. Is there a partner from a previous relationship who is making you feel unsafe now?

Despite significant evidence-based research, there is a hesitancy on the part of health care providers to screen.  The prevalence of screening is relatively low. A large study of physicians found that only 6% always screened their patients and 10% never asked their patients about intimate partner violence.² Medical providers are often hesitant to screen due to lack of time, a lack of training and knowledge, and a lack of resources in the community. At a basic level, some providers just feel uncomfortable with the topic and are worried about offending patients.

In 2013, the USPSTF recommended screening of all women of child bearing age for intimate partner violence. The evidence related to interventions is also positive. When a patient’s physician intervenes, patients experience a decrease in abuse on all levels.^3-9

As a medical provider, you hold a sacred role in the lives of your patients. You hold power through your position to make a difference in those silently suffering. The answer is simple: Just ask.

References

1. American Academy of Family Physicians. Intimate partner violence. Am Fam Physician 2011;81(10):1166-72.
2. Elliott L , Nerney M , Jones T, Friedmann P. Barriers to screening for domestic violence. J Gen Intern Med 2002 Oct;17.
3. Blair-Merritt MH, Jennings JM, Chen R, et al. Reducing maternal intimate partner violence after the birth of a child: a randomized controlled trial of the Hawaii Healthy Start Home Visitation Program. Arch Pediatr Adolesc Med 2010;164(1):16-23.
4. El-Mohandes AAE, Kiely M, Gantz MG, El-Khorazaty MN. Very preterm birth is reduced in women receiving an integrated behavioral intervention: a randomized controlled trial. Maternal and Child Health Journal 2011 Jan;15(1).
5. Kiely M, Ayman El-Mohandes AAE, El-Khorazaty M, Gantz MG. An Integrated intervention to reduce intimate partner violence in pregnancy: a randomized trial. Obstet Gynecol 2010 Feb;115(2 Pt. 1):273-83.
6. McFarlane JM, Groff JY, O’Brein JA, Watson K. Secondary prevention of intimate partner violence: a randomized controlled trial. Nursing Research 2006 Feb;55(1):52-61.
7. Miller E, Decker MR, McCauley HL, et al. A family planning clinic partner violence intervention to reduce risk associated with reproductive coercion. Contraception 2011 Mar; 83(3):274-80.
8. Taft A, Small R, Hegarty K, Watson L, Gold L, Lumley J. Mothers’ Advocates in the Community (MOSAIC)–nonprofessional mentor support to reduce intimate partner violence and depression in mothers: a cluster randomized trial in primary care. BMC Public Health 2011 March;11.
9. Office of the Assistant Secretary for Planning and Evaluation. Screening for domestic violence in health care settings. August, 2013. Accessed September 27, 2016. https://aspe.hhs.gov/report/screening-domestic-violence-health-care-settings