Domestic violence is such a prevalent issue in today’s world. Charlotte’s case is similar to many others. It is estimated that 2 million to 4 million US women are assaulted by a domestic partner every year. Twelve million women (25% of the female population) will be abused in their lifetime. Up to 35% of women and 22% of men presenting to the ED have experienced domestic violence. (http://www.findcounseling.com/journal/domestic-violence/domestic-violence-statistics.html) However, the precise incidence is unknown because domestic violence often goes unreported.
Introduction and Questions[]
This patient is a young Asian woman presenting with trauma to the right knee from a fall down the stairs. You discover the fall was preceded by a punch in the jaw from her husband.
How would you choose to proceed?
Domestic violence permeates all ethnicities, social classes and ages. Women stay in these relationships for many different reasons. Our patient Charlotte sites several common reasons including economic and psychological dependence on her husband. As her physician, how could you help her establish a sense of self-esteem and independence and thus bring her psychologically closer to leaving this destructive relationship? What community resources would you use?
The following quote was included in the facts section for domestic violence: "In Virginia, there are no requirements for reporting partner abuse to any state agency. Abuse of children, elders, and persons with disabilities are all reportable, but abuse of competent adults is not. However, state laws vary." What are your opinions regarding this omission in our state's law? Why would some states choose to ignore this patient population?
Discussion[]
If we have to wear helmets and seat belts, because of the proven safety records of their use (as well as the costs associated with NOT wearing them) why not require reporting of ALL assaults as criminal acts, and also apply civil penalties for the related health care costs? How much $$$ is lost to such preventable situations (lost wages, health care costs)? On the other hand, at what point have you then invaded someone's privacy, who does not wish to press charges? Hmmm.....
Also - if she was my patient, I'd treat the knee first, and work hard on building a relationship with her. In this scenario, it sounds like she might be willing to discuss options. The responses don't sound like she's shutting down to the interviewer.
It is always disturbing to read statistics regarding how common domestic violence is. It is common enough, so that we as health care practitioners often miss diagnosing it. Also, it is likely that we know people in the community who are victims without us being aware of it.
For this to be true, the victims are often able to hide the abuse, we as caregivers are not as good as we would want to be at discovering abuse, and we as a community are in significant denial about the issue. The problem of denial was brought home to me by a discussion I had with a young woman in the ER who had been physically assaulted by her boyfriend. The woman told me that her father asked her what she had done to provoke the boyfriend! Of course I reassured her that there was nothing she had done or said that justified her being beaten.
I actually disagree about having a law saying that we as physician should report domestic violence for a couple of reasons, the most important of which is the possibility of retaliation. In most domestic violence situations, it is a man that is abusing the woman....Most men begin with mental abuse by making the woman believe that she is can not survive without him and sometimes go as far as threaten her life if she tells anyone. If we begin to report these cases, and the woman is not mentally ready to leave, the man may beat her even more if he finds out that she told someone. Additionally, if we report the crime and the man is arrested, a lot of times a DA will not proceed with the case if the woman does not press charges (it depends on the degree of the assualt), and a lot of the times the woman will not press charges out of fear of not being able to survive on her own. If the man is arrested, when he gets out there is still the fear by most abused woman that he will find her and further harm her, so either way she is in continued danger. Lastly, I don't think we should report it because it is hard enough to get our patients to trust us, and if they feel as if we (as one of the few people that they can turn to) are further putting them in danger, then we won't be able to help them (mentally ) become strong enough to seek further help and leave the situation.
I agree that a physician should not be required to report every case of domestic violence, especially if the woman does not feel comfortable with the physician doing so. I think that any further actions would need to be agreed upon between the patient, whether it be a woman, or a man, and their respective physician.
However, first and foremost, the knee should be treated and then, if the patient is willing, the physician and the patient could have a conversation either that day in the office or a separate apppointment could be set up to confidentially discuss the situation.
I think it is important that we as future care providers should ask ourselves the question : where do we draw the line? Lets say the situation was a bit altered and there was not only a knee injury, but a severe head injury and internal bleeding, would this change the way the situation was dealt with? Now I'm not sure that there is an adequate answer to this question in that we all know our actions are effected by circumstance, however, the rates of spousal abuse are alarming and I wonder when we as physicians should draw the line and rally in support for those who must face such difficult situations because sometimes I think if we dont then who will.
The eMedicine article on Domestic Violence has a number of interesting points.
They mention that victims of domestic violence are likely to seek medical care frequently for conditions other than the injuries themselves.
"Women who are abused seek medical attention moreso than those who are not victimized. A study in the Northwest found that 95% of women with diagnosed domestic violence sought care 5 or more times per year and that 27% sought medical care more than 20 times per year."
Here is the link: http://www.emedicine.com/emerg/topic153.htm
I am not saying don't do anything about the abuse, but as the old saying goes " You can only help those who want to help themselves." I say work with the abused person (mentally) and with resources until they are ready to help themselves...it is very frustrating to watch this happen to someone (trust me I have seen it!) but at the end of the day, you can't control an adult. Children and elderly are different b/c children can not (legally) defend themselves and elderly may be to frail to leave.
Here's a question- how many times have you all been asked by a physician if you feel safe at your home? I'd say i've only been asked about 3 times in my life, 2 of which happened over break in Massachusetts! That's a little disheartening, because physicians are the people that should pick up on it the most, dont you think?
I spoke to someone last night regarding this case because I was curious as to what the actual procedure would be in Richmond if domestic violence was an issue. I didn't feel as if I knew exactly what to do if a woman told me she was being abused by her husband. What I learned was that, first and foremost, you have to assess what stage the victim is at this point in time, and meet her (him) there non-judgmentally (you guys already spoke about that). Depending on where she is at will guide your decisions from there. If she is willing to talk about it more and get more information, we can:
- develop a safety plan with her. This plan is supposed to consist of what she needs if she were to suddenly up and leave the abuser. Usually this 'plan' involves necessities, such as money, clothing for her (and children), cell phone, and basically anything that she thinks she would need to survive temporarily. we can tell her to put those things together and hide them in her house. when she needs to leave, she can grab and go.
- give her the number to the richmond ywca or richmond safe harbor, which are both women's shelters that deal with domestic violence. she can contact them directly. (we could also contact them, if she wants, while she is in the office i think too.)
- there is also a hotline number (1-800) that is available 24 hours a day ... they can provide support over the phone and refer to the appropriate services if need be.
thoughts?
I was also told that, as physicians, womens shelters are always open to establishing a line of contact directly through to us. setting up a meeting with your local women's shelter once we get out in practice is a great way to find out what to do.
I couldn't agree more..as you said "you can lead a horse to water but you can't make him drink." I agree that the support and possible alternatives thats we as physicians have to offer may be far outweighed by the risks that the abuser poses to the abused. I just feel that this circumstance is althogther too common. As a high school student I would volunteer at my mom's hospital in Brooklyn and the amount of domestic abuse I would see became routine. So routine in fact I feel like it was sometimes ignored and this is what disturbs me most.
I can certainly see where everyone is coming from... we should be able to report domestic abuse just as we are obligated to report child abuse but at what point are we violating our patient's autonomy? Certaintly it must be decided on a case by case basis. I think there is a line you draw as a practicing physician and that a knee injury can often be considered different than massive internal bleeding and a respirator. Just as we are obligated to hospitalize someone reporting suicidal thoughts, I think we might also need to hospitalize someone who stays in an abusive relationship, especially if the injuries increase in severity. Isn't this just another form of suicide? I've heard of physicians hospitalizing a patient if their immediate safety is considered compromised. My question to the physicians is have you ever considered this... and to the medical students, would you ever consider this?
I don't know about forcibly taking victims in for their own protection. At what point would you consider them "mentally ill" and in need of such care? That's kind of scary. What if you really were just a clumsy person, who had especially fragile bones, so you were in the ER a lot?
Here's an idea I saw once in a television interview with numerous couples in these kinds of relationships: how about mandating specialized joint counseling? Often these folks really do love each other. Usually these men appear normal to neighbors and friends, but need some serious anger management intervention as well as retraining, as they often saw their mothers beaten when they were children. In the interview I saw, the wives admitted that they know when their husbands are in bad moods, and that after years of beatings, they would actually begin to provoke them, just to have some measure of control. For them it erased the "dread" portion of it, and got it over with faster. It seems to me if this is really the case that BOTH partners need counseling in healthy relationships. Studies show that these women, if they do leave one abusive relationship, usually end up in another.
I guess what I'm saying is, not every man (or woman)that reacts badly is evil. Obviously there are some sociopaths out there, but if they really want to change but don't know how - don't you think a system to help these folks might be better than just taking the women out permanently? He'll just find another one (and she might also).
I don't know. No single fix will fit every situation. I just wondered if anyone else had thought of this, or if it just sounds nuts.
I tend to agree with the idea above about joint counseling in some of these situations. Both persons in relationships of this type often need help. Now I am not saying that whenever a woman/man comes in for this type of injury and we find out abuse is going on that we should immediately call up the husband/wife and invite him/her to a counseling session, but instead take advantage of any opportunity that presents itself to reach both people who are involved. This could involve talking to the abuser directly the next time the physician sees them as a patient, not in a confrontational way, but by asking them screening questions about abuse or anger management problems just as they would for any other patients. I feel that in a many cases, the abuser most likely knows that how they treat their significant other is not acceptable, but they have underlying anger management or other issues that cause them to act out against those closest to them. If we could get them to recognize their problems in such settings, they may be willing to change or seek help for themselves as they would for other health problems. Other opportunities would be when the abuser is the one who brings the patient in and acts overly concerned about their partner's healthcare. Many times the person doing the abusing actually brings the patient in to the ER or doctor's office. Again, without being confrontational, this issue could be brought up. It would be case by case dependent, and would be an uncomfortable thing to discuss, but as physicians we are trained in discussing uncomfortable topics all the time, why should we not intervene now when dealing with such matters that are directly impacting the current and future well-being of our patients. This does not mean reporting the case to authorities, but letting the abuser know that what they are doing in not healthy for all those involved, and that there are options for those involved to end this type of behavior.
The post above brings up a good point that was made in the eMedicine entry on domestic violence, that victims often seek medical care more often for other problems than their injuries more than those who are not being abused. To me, this makes the fact that domestic violence is so often missed that much more concerning. If simple screening questions about this topic were asked of everyone presenting to primary care docs and EDs we would pick up on it so much more. It is like anything else in medicine, if you go looking for it, you will find it. I think it is possible that these people who present multiple times to the ED with injuries, or for vague symptoms other than injury are often subconsciously hoping their other problems will be brought to light. In the emedicine article there is a simple set of screening questions that go by the SAFE acronym that could serve as an easy to remember screening tool for this problem.
The mnemonic SAFE directs inquiry into domestic violence. Sebastian, in 1996, maintained that simply asking the SAFE questions alleviates the patient's alienation, offers him or her an opportunity to validate his or her worth, and provides a means to assess safety. When SAFE questions are made routine, physicians become more comfortable in discussing domestic violence.
S: Stress/safety: What stress do you experience in your relationships? Do you feel safe in your relationships (marriage)? Should I be concerned for your safety?
A: Afraid/abused: What happens when you and your partner disagree? Do any situations exist in your relationships in which you have felt afraid? Has your partner ever threatened or abused you or your children? Have you been physically hurt by your partner? Has your partner forced you to have unwanted sexual relations?
F: Friends/family (assessing degree of social support): If you have been hurt, are your friends or family aware of it? Do you think you could tell them if it did happen? Would they be able to give you support?
E: Emergency plan: Do you have a safe place to go and the resources you (and your children) need in an emergency? If you are in danger now, would you like help in locating a shelter? Do you have a plan for escape? Would you like to talk with a social worker, counselor, or physician to develop an emergency plan?
To all who said treat the knee first. I wholeheartedly agree...I also think it would be important to treat the knee before initiating any conversation of domestic violence. It would obviously be important to use a pretty open-ended approach to addressing such an issue in any setting. It may warrant sneaking in a follow up visit to "check on the knee" in order to assess the patient's safety and possibly confront the situation somewhat detached from the initial incident. Maybe on the other hand it would be better to address the incident when seen on the first encounter with the patient in order to explore a situation that may be ignored when all is well. I think it abolutely comes on a patient by patient basis (like anything).
I do believe, however, that if it is a potentially life threatening gesture then it must be reported, end of story. It is our job to do our best to heal people, and first and foremost that means the knee. By doing this, we are in a position, thankfully in a lot of situations, to pick up on scenarios that might prove dangerous toward health in the future such as domestic violence. By reporting life threatening gestures in the domestic setting, we probably save ourselves from some liability as well. Obviously that is not what it is all about, but something to remember.
I approach the difficult issue of domestic violence during the initial visit. The patient may not return for follow up, perhaps due to choice or maybe because the domestic situation does not allow for return to the doctor's office.
It is important for the physician not to miss this opportunity. We need to make the patient comfortable discussing sensitive issues; we can do this by showing the patient that we are open to understanding their domestic situation, now and at all future visits.
I agree that the issue of domestic violence should be discussed at the initial visit.
The suggestion of couple's counseling sounds interesting, but this is probably only done in a few centers at this point. One would have to have contact with a specialist who was doing this, perhaps in a study or pilot program. This would not be something that I would recommend trying in the family physician's office.
I don't know that I would feel comfortable asking the abuser screening questions. My first instinct would be to help the person being abused out of danger (into a shelter) and then find help for the other party. My reasoning is this: I do believe that people can change and that most abusers are probably willing to change with some counseling, but I would just be afraid of that one man/woman who really is a psychopath who would smile in my face and then go home and beat the other party senseless for even discussing the issue. It would probably be a rare case of this happening, but I don't think I would be willing to risk it with even one life...then we as physicians have to think of our safety too...what about the person who explodes on you because they don't even like the suggestion that something may be wrong with them and that you even had the audacity to suggest that they needed counseling.
Maybe most of the time the abuser will not be with the abused in the office? I haven't had any experience with this. If in fact the abuser was present, it would obviously help to interview the patient/abused alone. Obviously this would be met with a certain degree of resistance. The initial remark would generally be something like "i would prefer to talk to mr or mrs X alone, would you mind leaving the room?" . Again, I have very little experience with this, but I assume in a lot of cases this wouldnt do the job, esp. if the victim is frightened. What techniques would you guys use if the couple is uncooperative? I would probably wait until the physical exam, and ask the abuser to leave, continuing with the interview through the exam and then afterwards. It would obviously help to get a nurse to show them to the waiting room or somewhere detached.
Recommended Resources[]
The eMedicine article on Domestic Violence has a number of interesting points.
http://www.emedicine.com/emerg/topic153.htm
http://www.findcounseling.com/journal/domestic-violence/domestic-violence-statistics.html
Links to Cases[]
Back to Charlotte or Case studies.