Family violence: Practical recommendations for physicians and the medical community

Family Violence: Practical Recommendations for Physicians and the Medical Community Sarah M. Buel, JD, Harvard Adjunct Adjunct Assistant Norfolk

Professor, Harvard Medical School Professor, Boston College School of Law District Attorney County, Massachusetts

M

any were outraged by the 1988 murder of 6-year-old Lisa Steinberg by Joel Steinberg, her adoptive father. Mr. Steinberg also brutalized Lisa’s adoptive mother, Hedda Nussbaum. On February 12, 1988, Mrs. Nussbaum was referred to the Bellevue Hospital Emergency Room from a battered women’s shelter, due to the severity of her injuries. Ms. Nussbaum presented with multiple fractures, explaining that she had fallen down a flight of stairs. Fortunately, the physicians determined that the injuries had been sustained in a beating. She was treated and admitted to the Bellevue Psychiatric Unit for 5 days. At that time she disclosed the truth of her own abuse and that of her children. Yet on February 17, 1988, Ms. Nussbaum was released to her battering husband’s custody. The hospital’s report was referred to the New York City Department of Human Resources, but its investigation found no evidence of child abuse,’ apparently deeming the serious injuries to Hedda Nussbaum to be of no consequence. Since Hedda Nussbaum’s hospital visit many physicians, nurses, and medical professionals have made great strides in developing more effective interventions with family violence victims. These efforts are due, at least in part, to the leadership roles taken by the American Nurses Association, the American College of Obstetricians and Gynecologists (ACOG), and the American Medical Association (AMA). Each has produced comprehensive guidelines, standards of practice, and informational materials to assist medical irofessionals in improvmg their practices. These publications have contributed significantly to the available domestic violence literature and have served as a catalyst to galvanize other professional organizations to action.* For example, there now exists a nationwide program to provide free reconstructive surgery to indigent battered women. Advocates herald the program, as a victim’s recovery can be impeded by constantly being forced to see the scars of abuse.2 Additionally, many state medical organizations and specific commissions have taken up the difficult challenge of producing practical materials for the

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0 1995 by The Jacobs Women’s Health 1049-3867/95/$9.50

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1049-3867(95)ooo56-9 *Citing the exemplary efforts of the American Medical Association, the American Bar Association cosponsored a conference on Domestic Violence in March of 1994.

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professionals and the battered patients. The Massachusetts Medical Society produced an outstanding packet, Campaign Against Domesfic Violence,* then mailed it to every physician in the state. They have followed up with articles, seminars, press releases, and the formation of the Physicians Domestic Violence Roundtable to provide the opportunity for information-sharing, collaboration, and training. The AMA has established a committee to draft guidelines for the integration of domestic violence into the curricula of medical schools. It is noteworthy that this committee is chaired by the prestigious Dr. Edward Brandt, now a professor of health administration and policy and the director of the Center for Health Policy at the University of Oklahoma Medical School, is also the former Assistant Secretary of Health and Human Services. It is not surprising that in his native Oklahoma, Dr. Brandt also chairs the Oklahoma State Medical Association’s Committee on Domestic Violence. He was instrumental in organizing a multidisciplinary effort to address the issue, including the publication of a manual, Do Your Paatienta FAVOR, End the Silence. (The acronym FAVOR stands for Family Abuse and Violence Oklahoma Physicians Respond.) Dr. Ronald Chez, professor of obstetrics and gynecology and of community and family health at the University of South Florida College of Medicine and Dr. Richard Jones of Hartford, Connecticut, co-chaired a committee that produced a 72-slide set on domestic violence. ACOG will be creating at least 400 copies of this slide set to allow each medical school and residency program to obtain a copy. The purpose of the set is to integrate domestic violence as part of the resident education program in obstetrics and gynecology. Each slide is accompanied by a text of one or two paragraphs, allowing lecturers, as well as individuals, to use the materials. Increasingly hospitals are inviting domestic violence experts to present on domestic violence issues at grand rounds,t medical schools are inviting guest lecturers on the topic,+ and medical organizations are highlighting this area at their educational training pr0grams.s Dr. Richard Jones, as president of ACOG, probably began the trend when he made domestic violence the cornerstone of his presidency, speaking world-wide on the issue and instituting major changes in his own practice and hospital. Dr. Jones was the catalyst for tremendous efforts, including providing domestic violence materials to every ACOG member and arranging a panel of colleagues to present on domestic violence as the presidential program at the ACOG Annual Clinical Meeting in 1993.” Initial questions might include the following: Why should health professionals get more involved in family violence issues? Isn’t this best left to the criminal justice system? If it’s so bad, why don’t the victims just leave? First, the community desperately needs the involvement of medical professionals because so often they are the front line: the first to see a victim or the first person in whom the victim will confide about the abuse. This affords the physician the opportunity to intervene with safety planning and a myriad of resources that can prevent further harm and possible homicide. As achieving and maintaining good health for patients are medical goals, safety must surely be seen as part of that paradigm. Second, courts have been more willing to hold hospitals liable for the acts or omissions of their staff, with clear responsibility on the shoulders of physicians, nurses, and other hospital employees. A string of recent cases has not so much suggested that the hospitals caused the negligence, rather that they did not act responsibly to prevent it. A 1991 Pennsylvania Supreme Court opinion stated that not only must physicians follow the standards of care, but that nurses and other hospital staff are obligated to “question a physician’s order which is not in accord with standard medical practice.“3 Given that

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*The packet and accompanying booklet, “A Phvsician’s Guide to Domestic Violence,” was authored by Dr. Elaine Alpert, Chair of the Massachusetts Medical Societv’s Domestic Violence Committee, with Dr. Karen Freund, and three then-medical students, Catherine Park, Jagruti Patel, and Mika Sovak.

tEg, the author has spoken on domestic violence for grand rounds at area hospitals in Boston; Lowell, Masachusetts; Honolulu; Columbus, Ohio; Savannah, Georgia; Philadelphia; and San Francisco

$Eg, the author has been a guest lecturer at the following medical schools: Harvard, Boston University, Tufts, Mount Sinai, Jefferson (Philadelphia), University of Hawaii, University of Massachusetts, University of California (SF), Ohio State University, and others.

§Eg, Dr. Elaine Alpert and the author were invited to present two sessions at the American College of Physicians Annual Conference in Atlanta, March 17 and 18, 1995.

‘The panel consisted of Dr. Jones, Ronald Chez, a physician-survivor, the author. .

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routinely asking patients about abuse (ie., on every visit asking, “Have you been hit or threatened since the last time I saw you?“) is now considered the standard of care, it is clearly the medical professional’s failure to ask that will subject him or her to potential liability. Third, family violence cannot simply be left at the doorstep of the police, courts, shelters, emergency medical providers, or any one community entity. It is only in those communities with a multidisciplinary, integrated response that a reduction in family violence is achieved. The city of San Diego, by forging a close police, prosecutor, medical, mental health, and educator partnership, has reduced its domestic violence homicide rate by 59% over the past 2 years.4 Phoenix has achieved a 30% reduction in its domestic homicide rate by instituting a similar protocol.5 The Nashville Metropolitan Police Department boasts a 71% drop in its domestic homicide rate for 1994 and the first quarter of 1995, as a result of the establishment of a similar coordinated community response.’ The recommendations contained herein do not represent an effort to “medicalize” the problem of family violence, but rather to identify the most productive roles for medical professionals, given the need for cross-disciplinary involvement. For each profession (eg, law, education, mental health, business, religion, and social work) similar corresponding guidelines have been developed. Although it is important to recognize that there are, indeed, male victims of domestic violence, well over 90% of the victims are female. The U.S. Department of Justice’s Bureau of Justice Assistance reports that females are ten times more likely to be the victim of a violent assault by an intimate than are males.’ Similar patterns of intimate violence continue with homicide data. Three percent of male homicide victims were murdered by their wife, ex-wife, or girlfriend, yet approximately 30% of female homicide victims were murdered by their husband, ex-husband, or boyfriend.’ As we improve outreach and service delivery to lesbian and gay victims, the gender-based data are likely to reflect same-sex battering and homicides more accurately.Y Perhaps the most asked question, “Why doesn’t the victim just leave?” assumes that leaving will achieve safety. In fact, numerous researchers have documented that leaving is the most dangerous time for domestic violence victims. Dr. Angela Browne, in her outstanding book, When Battered Women Kil1,*2 found that more battered women were killed in the process of leaving than at any other time. Thus, advising a victim to leave without first providing a safety plan is dangerous and contraindicated. Furthermore, as Judge Albert Kramer asserts, batterers are probably the most tenacious and dangerous defendants with whom we work; they will often continue the stalking, harassment, and abuse even after remarriage, new relationships, and long time spans.* One reason that every state and the District of Columbia and Puerto Rico now have stalking statutes*” is that many batterers begin dangerous stalking behavior immediately after the victim flees. It is also important to state that focusing on the victim’s assumed obligation to flee unlawful abuse is victim-blaming and must stop. Instead, we must ask, “Why do we, as a society and community, allow such horrendous levels of violence primarily against women and children?” and “Why do batterers harm those they profess to love?” and “Why are we not holding the batterers accountable for breaking laws?” In my personal and professional experience,+ there are many valid reasons why a victim would not flee the abuse early on or would return to a battering partner. A class of fourth-graders gave the following 27 reasons why victims stay (I have taken the liberty of paraphrasing): 1) Fear of being alone and of retaliation 2) Lack of money 3) No place to go, no housing, and/or no room at the shelter

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*Judge Albert Kramer was then the presiding judge of the Quincy, Massachusetts, district court, speaking on 60 Min&es,

CBS

TV,

February

7, 1992.

+The author is a survivor who has worked with thousands of battered women over the past 19 years, in five different states in courts and shelters as an advocate, prosecutor, legal services paralegal, and shelter volunteer.

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4) Trying to protect the children, both from the batterer and a child protection agency that may threaten to take the children if the victim cannot stop the abuse 5) Unable to speak English 6) Religious beliefs 7) Wanting to keep the family together 8) Substance abuse problems 9) Trying to protect the abuser 10) No job skills 11) No affordable and/or available day care 12) Guilt, belief it’s all her fault 13) Low self-esteem, thinks she does not deserve any better 14) Grew up in a violent home,thinks it is normal for families to be violent 15) Fear of immigration authorities and deportation 16) Prior bad experiences with police, courts, or helping agrncles 17) Fear that nobody will believe her 18) Isolation: is kept away from and not able to locate help 19) No knowledge of available resources and no access to them, such as legal services, advocates, or attorneys 20) Believing the children need their father or father-figure in the home 21) For lesbians and gays, fear of coming out and possibly losing job, family, and community support 22) For handicapped or hearing impaired, assumption that serviceswill not be able to accommodate, coupled with belief that no one else will want them 23) Culture, particularly those who ascribeto what they believe are the traditional norms (it is important, however, not to ascribe familv violence to anv one culture as it is prevalent in most all) 24) Wanting to save the marriage or relationship 25) Family or social pressure: well-intentioned friends and family may untvittinglk offer support to the batterer 26) Love and hope: the victim may believe that if she just improves her behavior, her love will be returned, or that the abuser will realize he is destroying his family and the relationship and be motivated to stop the violence 27) Promisesof change: many batterers are contrite after the abuse and beg the victim to give them just one more chance. Additionally, many batterers threaten that if the victim discloses the abuse to anyone, that worse harm will befall her and/or the children. Thus, simply disclosing the abuse is a terrifying prospect for many victims. For those who are elders, gay or lesbian, handicapped, migrants, prostitutes, teens, infected with human immunodeficiency virus (HIV),” or from other

under-served populations, the fear of reporting is compounded by the real or perceived lack of services addressing their unique situations. Given such obstacles, but in the spirit of the ground swell of activity and progress, I offer the following recommendations. RECOMMENDATION AND Know

and Use Community

#l: EDUCATE COLLEAGUES

YOURSELF

Resources

Find out about visiting shelters (if permitted) and determine what services you and/or other medical professionals and students might provide in such settings. For example, in some communities, physicians and nurses are going into shelters to provide health services to victims and their children. Other physicians, such as Dr. Elaine Alpert in Boston, have offered free medical care to victims and arrange with colleagues to assist with other needs. By speaking with victims, offenders, and children who have lived with the abuse, medical professionals can learn more about what interventions are most helpful.

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BL’EL:

“Dr. BarbaraHerbert, an emergency room physicianat BostonCity Hospital, hasbeenstudying, writing about, and assistingbatteredwomen who are infected

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However, only trained batterer’s therapists should take on the task of confronting the batterer and determining what intervention program is most appropriate. Well-intentioned, but misguided advice at a recent medical conference suggested that the physician could align himself or herself as an ally of the batterer, working together to stop the violence. Noted batterers’ expert Dr. David Adams cautions that not only can the batterer dupe the doctor into believing that the abuse has stopped when in fact it may be escalating, but such intervention can be quite dangerous for the victim, physician, and staff. The role of the physician with the victim is to 1) routinize inquiry about abuse, 2) discuss safety planning, 3) state clearly, “You do not deserve to be abused,” and 4) refer to appropriate shelter and advocacy programs. In working with the abuser, the provider’s role is to refer the batterer to a certified batterer’s intervention program, where a danger/lethality assessment and treatment plan can be completed. In Boston, several nurses and doctors participated in police ride-alongs to gain a better understanding of what their crisis response involved. Some have found it helpful to attend a batterer’s intervention program meeting, to learn more about the ways that a sense of entitlement to power and control impact the batterer’s behavior over time. Many medical professionals have also learned a good deal by asking experienced advocates about areas of concern and how they can help.

Use National Resources Particularly useful is the National Domestic Violence Health Resource Center, (800) 313-1310, which is designed specifically to provide medical professionals with technical assistance, training materials, posters, bibliographies, and relevant articles (eg, on the inadvisability of mandating physician reporting of domestic violence incidents). Additional information, guidance, and relevant bibliographies are available from other organizations, including the National Clearinghouse for the Defense of Battered Women, (215) 351-0010; the National Center for Women and Family Law, (212) 674-8200; the National Coalition Against Domestic Violence, (303) 839-1852; the National Council of Juvenile and Family Court Judges’ Domestic Violence Project, (800) 52PEACE; and the National Domestic Violence Resource Center, (800) 537-2238. Your national and local medical and nursing organizations should also be able to assist with materials and information.

Read Relevant Books and Articles Especially relevant are “Domestic Violence: Let Our Voices Be Heard” by Dr. Richard Jones (Obstet Gynecol 1993;81:14), and “60 Ways to Stop Domestic Violence” by Elizabeth Austin, Jeremy Mindich, and David Ruben (Self 1994; (Nov):172). (See also Limited Bibliography.) Subscribe to newsletters and relevant publications, for example, the AMA’s newsletter from its Physicians Family Violence Committee, (312) 464-5702, and the excellent quarterly newsletter, The Advocufe (available for $30 per year), from the National Center on Women and Family Law, (212) 674-8200). Several other national and state organizations also publish relevant publications. ACOG, (800) 673-8444, has excellent materials and staff available to assist interested physicians. You may also view videotaped materials, such as the domestic violence training tapes available from both Wyeth-Ayerst Laboratories, (800) 234-9929, and Ortho Pharmaceutical Corporation, (800) 682-6532, as well as the Academy Awardwinning documentary Defending Our Lives, which is available from Cambridge Documentary Films, (617) 354-3677.

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Institute Mandatory Your Work Setting

and Frequent Domestic Violence Training

Such trainings must be mandatory, them. The sessions should be held issues and provide an opportunity questions. The training objectives

in

otherwise those most in need tend to avoid with regularity to stay abreast of emerging for staff to voice problems, concerns, and might be as follows:

1. For participants to become familiar with the background dynamics of family violence, including why victims stay and the importance of having a safety plan. 2. To understand the importance of action planning and to routinize inquiry about abuse to increase the effectiveness of medical interventions 3. To become familiar with the legal obligations and liability risks of physicians in reporting and treating family violence victims

Medical practitioners should also attend domestic violence conferences, request that domestic violence service providers speak at grand rounds and local medical society meetings, and participate in local family violence roundtables, coordinating councils, or task forces. The educational and action efforts that have been reviewed here can help you understand the myriad of obstacles to victims leaving and some of the valid reasons why they might return to the batterer, in spite of outside help. (See previous section for the list of reasons children gave as to why a victim might stay.)

Victim Presentations Frequently, the assumption is made that if no bruises are visible, that the patient is not a domestic violence victim. The following represents the short list of presentations that should at least trigger concern that the patient might be a domestic violence victim in dire need of your assistance: 1) 2) 3) 4) 5) 6) 7) 8) 9) 10) 11) 12)

Patient’s story not consistent with injuries Delay between onset of injury and presentation for help Multiple injury sites Injuries at different stages of healing Substance abuse (often self-medication) Any injuries on a pregnant woman, especially on the stomach, or breasts High anxiety, depression, and/or suicidal ideation Frequent headaches Gastrointestinal problems Hypervigilance Frequent visits, either with or without injuries Low self-esteem

abdominal

area,

Needless to say, such presentations do not guarantee that the patient is being abused, rather their presence raises the possibility and warrants further inquiry.

RECOMMENDATION #2: BE WILLING INDIVIDUAL AND INSTITUTIONAL Routinize Inquiry

TO CHANGE PRACTICES

About Abuse

The standard of care requires that each patient is asked on every visit, “Have you been hit or threatened since the last time I saw you?” If the patient is being seen for the first time, an explanation can be offered: “Due to the high

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incidence of domestic violence, I ask each patient whether they have been hit Victims may not be able to disclose or threatened in a personal relationship.” the abuse without inquiry initiated by the medical practitioner. Pennsylvania triage nurses found that simply by asking about the history of abuse, they increased their identification of domestic violence victims by 60%. Dr. Richard Jones reports that prior to his routinizing inquiry about abuse, he identified just a few cases per year, whereas by asking directly, “Have you been hit or harmed anytime in the past year ?‘I he now sees two or three cases per week in his practice.14 Certainly if a physician with the stature, experience, and knowledge of Dr. Jones is willing to adapt his patient interview practices, then the rest of us have little reason not to follow suit.

Safety Plan Without an action plan for how to stay alive, many victims are subjected to further harm and even death. The Appendix offers an example of an excellent domestic violence safety plan. This safety plan can be more important than a protection/restraining order or criminal trial in encouraging the victim to consider many facets of her/his survival strategy. Although some suggestions may seem obvious (eg, change the locks on your door or carry a copy of your restraining order on your person at all times), it is difficult to think of such details in the midst of an abusive incident or in the process of fleeing the abuser. Additionally, some of the safety plan’s suggestions are based on recently gained knowledge, such as the advice to stay out of the kitchen when an abuser is violent. Because of the access to knives in the kitchen, this can be the most dangerous room in the house. Taping the safety plans in bathroom stalls and examining rooms has proven to be an extremely effective means of distribution, as it eliminates the embarrassment victims may feel in taking the brochure in a public waiting area. Although the physician or nurse does not have to go over the safety plan in great detail, it is quite helpful for victims if the medical practitioner at least makes reference to some of the safety plan’s suggestions that might be particularly relevant in that patient’s case.

Take Part in Family and/or a Physician’s

Violence Coordinating Roundtable

Council,

Task

Force,

It is critical that interdisciplinary networking occurs, enabling medical professionals to share their concerns, questions, and expertise with other relevant community providers. Serving on the American Bar Association’s Domestic Violence Commission, Dr. Robert McAfee (representing the American Medical Association as its 1994-95 president) has been a critical player in forging policy, action plans, and a greater understanding of the medical community’s possible contributions. Dr. Elaine Alpert, assistant dean of students at the Boston University School of Medicine, practicing internist, and chair of the Massachusetts Medical Society’s Domestic Violence Committee, has been an invaluable participant on the Massachusetts Governor’s Domestic Violence Commission and is active as the co-founder of the Massachusetts Medical Society’s Domestic Violence Roundtable. Dr. Alpert has been of tremendous assistance to the legislature and policy makers in the reform efforts underway to eliminate discrimination against battered women by the insurance industry, in charting medical school curricula changes, improving patient care, and alerting providers to the dangers to abuse victims even as they seek help. Much needed collaboration and problem-solving efforts can be addressed in such a forum. For example, in a meeting of the Greater Boston Family Violence Roundtable (this has since become the Governor’s Domestic Vio-

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lence Commission), an emergency room nurse brought to the group’s attention that several police officers were refusing to provide emergency restraining orders to victims. The nurse recounted that she had to threaten to call a news reporter to prompt the right action, which another nurse later said she used successfully in a similar incident. The police representatives attending the meeting began an investigation and were able to improve the services as a result. Document

Accurately

and Legibly

Since medical records assist in creating a paper trail documenting the abuse, it is particularly important that they be both accurate and legible. When some insurance companies began denying coverage to abuse victims, the concern was raised that perhaps physicians should not write a diagnosis of domestic violence in the medical record. The fear was that this information could be used as the basis for denying insurance coverage to battered women. However, substantial pressure has been brought to bear on the insurance industry, forcing them to change their policies of direct denial and replacing them with higher premiums.15 Although it is still a concern that documentation of domestic violence could adversely impact the victim’s ability to obtain affordable insurance, the benefits of such documentation outweigh that possibility. Additionally, physicians can creatively word the medical record to reflect that the injuries were inflicted by an intimate partner, without flagging it as a “domestic violence” case. One reason to document carefully is that medical records are readily admissible at civil and criminal trials, providing an objective diagnosis that can substantiate and bolster the victim’s assertions of harm. Clear medical records can help the judge and/or jury understand the true nature and severity of the injuries, even if the victim is too terrified to testify or to fully describe the incident. Additionally, a growing number of states are following the recommendation of the National Council of Juvenile and Family Court Judge’s Model State Domestic Violence Code that there be a rebuttable presumption against sole or joint custody being awarded to a perpetrator of domestic violence. l6 As many victims may turn first or solely to medical providers, the medical record may be the only documented evidence of the abuse, and thus the only means for the victim to show that the perpetrator should not be given custody of the children. A second reason to document domestic violence carefully is that such a diagnosis can trigger referrals to appropriate shelters and the development of a safety plan, as occurred in the Hedda Nussbaum case. A third reason to fully document findings of domestic violence is that the physician can then also state the referrals and actions taken. Such information can greatly protect the physician should a malpractice claim allege failure to provide the standard of care. It is the physician’s failure to act that will incur liability, not good faith efforts to assist the victim.

Ensure that Your Hospital or Program

Has a Domestic

Violence

Advocate

Susan Hadley, a Minnesota nurse, determined to increase identification of and treatment services to battered women, started WomanKind programs at three Minneapolis area hospitals (see page 189). Initially, she says they focused on emergency room interventions, assuming that most battered women would present there. However, once they began an effort to familiarize the institutions with their program, the referrals from orthopedics,

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mental health, obstetrics/gynecology, pediatrics, and other departments far outnumbered those from the emergency room. By having advocates on site at the hospitals, physicians and nurses were much more likely to refer victims, and victims were much more likely to avail themselves of the offered services, Through Project AWAKE (Advocacy for Abused Women and Kids) at Boston Children’s Hospital, the mothers of all abused children are also screened for abuse. The program was started in the mid-1980s as the hospital staff recognized that they could not protect children if they ignored the mother’s abuse. By linking the mother/abuse victim with an advocate, chances greatly increase of being able to keep the nonviolent family members together. The advocate assists with court and social service advocacy, support groups, individual counseling, varied information, and referrals. To combat low birth weights and infant deaths, AWAKE recently located an advocate in a public housing project that is 25% African American and 75% Latino. The advocate was delighted to receive ten referrals just in the first week. AWAKE is sensitive to culture, race, and socioeconomic issues, with two Spanishspeaking advocates and a well-trained staff. In addition to offering support groups for children ages 6 to 10, they provide education and support groups for the abused mothers. AWAKE staff also provide training for physicians and nurses, as well as community providers, who often are not aware of the abuse dynamics and are reluctant to ask about abuse. Most victims readily accept the help; only five or six of more than 300 women referred in 1994 refused the offered services. AWAKE director, Jennifer Robertson, asserts that, “Battered women aren’t looking for counseling or advocacy services when they come to a hospital, but they are thinking about leaving their abuser. It’s a good time to talk to them.“” If you practice outside of a hospital, a separate unit may not be feasible, but you can ensure that all staff receive comprehensive family violence training. This will increase the likelihood that effective early identification, treatment, and referrals are made.

Integrate Family Violence into the Curricula of Medical, Nursing, Social Work, and Relevant Professional Schools The Centers for Disease Control and Prevention has documented that most medical schools spend less than 1.5 hours on family violence throughout the entire 4-year period, with most of that focused on child abuse. Most nursing and social work schools, as with other graduate and specialized programs (for example, law, religion, education, law enforcement, etc) have also failed to provide their students with critical information regarding effective interventions, legal and ethical obligations, dynamics of family violence, and other relevant topics. Fortunately, some institutions are taking the lead in changing that inexcusable state of affairs. For the past 6 years, Dr. Elaine Alpert at Boston University School of Medicine has been bringing in guest speakers, coordinating symposia, and requiring her students to read, discuss, and strategize about domestic violence as it will affect their patients and co-workers. Dr. Alpert also makes it clear that students cannot pass her course without substantial knowledge about family violence. Additionally, she has served as the faculty advisor for the Boston University Medical Students Against Domestic Violence, an active group that volunteers at local domestic programs and assists Dr. Alpert in her medical society efforts. As mentioned previously, Dr. Edward Brandt is heading the AMA’s committee to establish guidelines for medical schools to integrate instruction on family violence at every level of a physician’s education. Both Drs. Brandt

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and Chez have successfully woven the topic into their course materials. Harvard Medical School has invited guest speakers to explain the dynamics of domestic violence to all first-year students and set up problem-solving sessions with more advanced literature reviews for third-year students after their clinical rotations. In the fall of 1995, domestic violence advocates and survivors were also invited to present at a day-long faculty briefing session, which included role plays and break-out groups. In addition to changing the core curricula, existing protocols and accreditation criteria must be expanded to include, as an academic subject, the issue of family violence. Nursing, social work, and medical schools must acknowledge that their failure to provide such cutting edge information as part of the core curriculum greatly interferes with their students’ ability to best serve their patients.

Ensure that Professional Medical Organizations Combating Family Violence

Are Active in

Increasingly, national, state, and local medical associations are taking a leadership role in the efforts to eradicate family violence. In addition to those mentioned in the introduction, medical societies in California, Florida, Iowa, Minnesota, North Carolina, Oklahoma, Tulsa County (Oklahoma), Oregon, and Texas, among others, have undertaken a range of domestic violence training and education activities. The California Medical Association sponsored a series of six public service announcements (PSAs), “Safe Choices,” urging battered women to confide in their doctor or call 800-TRY-NOVA for help. Ron Lopp, at (415) 8825115, may be contacted to obtain more information regarding the PSAs. In concert with medical students at the University of Texas Medical SchoolHouston, the Texas Medical Association set up a six-part lecture series on a wide range of topics related to family violence. The “Stop the Violence” campaign of the Minnesota Medical Association provides PSAs, billboards, and bumper stickers, in addition to guidelines and resources to doctors. Contact Mark Vukelich at (800) 999-1875 for additional information. In North Carolina, the state’s Medical Society and medical students from East Carolina University School of Medicine sponsored community education seminars at a local mall. Additionally, they distributed walletsized information cards, and held a raffle to raise money for their local battered women’s shelter. Donald Wall at (919) 833-3836 may be called for more information. Producing pocket-sized information cards (in Spanish and English), as well as fact sheets on its new stalking law, has proven to be an important initiative for the Oregon Medical Association (OMA). OMA also ran a l-day conference on the health provider’s role in family violence cases and included family violence features in several of its publications. The Florida Medical Association and the Florida Bar Association co-produced a 30-second PSA with information for victims and their families. Kathy Zamora should be contacted at (904) 356-1571 for additional information. la Sponsoring training seminars, publishing relevant articles and practice guidelines, and producing community education materials have proven to be invaluable contributions by medical groups from around the country. Formulated in collaboration with shelters and community agencies, such information has not only provided guidance to physicians, but also to victims in danger. Organized medical groups have much to offer their communities in the area of domestic violence and should not wait for future tragedies before taking action.

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RECOMMENDATION #3: INITIATE COMPREHENSIVE COMMUNITY EDUCATION Medical providers are in a unique position to dispense much-needed information to the community by virtue of 1) stature and believability: “If my nurse or doctor has posters, brochures, and videos on domestic violence, maybe this really is an important topic”; 2) opportunity: From health clinics, private offices, and hospitals to rural home visits, many more family violence victims see a medical provider than any other professional; and 3) ethical responsithe medical practitioner is in a bility: Often the most trusted intervener, strong position to prevent repeat assaults and even homicide. This does not have to be a complicated or expensive endeavor. By contacting the local battered women’s shelter, the practitioner can obtain brochures and resource materials. For additional information, the National Domestic Violence Health Resource Center at (800) 313-1310 can provide posters, brochures, bumper stickers, articles, etc for local use. Remember to tape copies of your local safety plan in your office and community bathroom stalls. The safety plan in the Appendix is not copyrighted and can easily be adapted for any area by simply adding a local shelter or police department’s name and replacing the resource phone numbers.

RECOMMENDATION ENVISION

#4: WE MUST HAVE THE COURAGE THE CHANGES NEEDED TO END FAMILY VIOLENCE

TO

Instead of hiding behind the usual excuses, “I don’t have the time or money or human resources to improve practices . . . , ” we must each be willing to view the obstacles as challenges. Those medical practitioners who have dramatically improved interventions faced similar, if not the same or more awesome stumbling blocks. Yet, like Drs. Richard Jones, Elaine Alpert, Edward Brandt, and Ronald Chez, they were willing to leave defensive egos behind and ask themselves, “How can I improve what I do? How can I do an even better job at assisting patients who are victims?” This process involves seeking the advice and guidance of experienced domestic violence advocates who can best steer the well-intended practitioner. For many of us who have spent decades working to end family violence on shoe-string budgets, it is the power of visualizing reform that helps prevent burnout. Once you have identified that which you want to change, or if you are unsure of the direction to steer, visualize that which you seek coming to your assistance. Susan Taylor, the extraordinarily talented editor of Essence magazine, suggests that we write the following affirmation near our bedside or bathroom mirror to facilitate our saying it aloud every morning: “All that such as this can I need is streaming toward me. I can feel it. “19 Affirmations create the mind-set to welcome innovative solutions and have proven quite successful in both personal and professional applications. If nothing else, affirmations can help clear away the myriad of excuses generally obstructing progress. In summary, medical professionals should make every effort to do the following: 1) Educate yourself and colleagues about effectively combating family violence 2) Be willing to change individual and institutional practices to better protect patients who are domestic violence victims

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3) Initiate comprehensive community education efforts to avail patients, coworkers, and the community of the information and safety plan available to them 4) Envision the changes needed to end family violence and by-pass the excuses obstructing reform efforts. Having spent 19 years working with abuse victims in five states, as an advocate, survivor, and prosecutor, I can attest to the significance of health professionals’ involvement in the above four areas. Certainly, these recommendations are not all-inclusive, nor are they meant to be limiting. Rather, they constitute a short list of starting points specifically designed for practitioners. The efforts of battered women’s advocates have been greatly enhanced and our spirits uplifted by the involvement of the many physicians

and nurses who labor tirelessly to increase victim safety and community involvement. I ask you to find the courage to work toward implementing at least the four recommendations listed herein, with the greatest emphasis on the safety

plan.

REFERENCES 1. Sullivan R. Nussbaum is said to want to testify at Steinberg trial. The New York Times 1988 May 9;Sect. B:l(col. 2). 2. Across the USA: news from every state, New Jersey. USA Today 1995 March 7;Sect. A:G(col. 3). 3. Felsenthal E. String of rulings open hospital to more liability for malpractice. The Wall Street Journal 1993 Jan 13;Sect. B:6(col. 1). 4. O’Dell A. Proceedings of the American Probation and Parole Conference; I994 Sept. 12; Phoenix. 5. Mesino C. Proceedings of the American Probation and Parole Conference; 1995 Sept. 12; Phoenix. 6. Wynn M. Effective police practices in domestic violence. Proceedings of the Florida Family Violence Conference; 1995 May 16; Melbourne (FL). 7. U.S. Dept. of Justice, Bureau of Statistics. Selected findings, domestic violence: violence between intimates 2-3. Washington (DC): U.S. Dept. of Justice, 1994 Nov. 8. Bachman R, Saltzman L. National Crime Victimization Survey, violence against women: estimates from the redesigned survey. Washington (DC): U.S. Dept. of Justice, Office of Justice Programs, Bureau of Justice Statistics, 1995 Aug. Report No.: NCJ-1543438. 9. Lobe1 K (ed). Naming the violence: speaking out about lesbian battering. Gay Community News 1989 April 16-22:9-10. 10. Robson K. Lesbian (out) law: survival under the rule of law. Gay Community News 1992; (July). 11. Reed J. Naming and confronting gay male battering. Gay Community News 1989;(April):9. 12. Browne A. When battered women kill. New York: The Free Press, 1987. 13. Salame L. A national survey of stalking laws: a legislative trend comes to the aid of domestic violence victims and others. Suffolk Univ Law Rev 1993;27:67-111. 14. Jones R. Domestic violence: let our voices be heard. Obstet Gynecol 1993;814. 15. Public Affairs Dept. State Farm defines policy on coverage for domestic violence victims [Press Release]. Bloomington (IL): State Farm Insurance Co., 1995 May 31. 16. National Council of Juvenile and Family Court Judges. Family and children. In: Model state domestic violence code. Reno (NV): NCJFCS:33-8. 17. National Crime Prevention Council. Children’s hospital reaches out to abused mothers. In: Preventing violence against women, not just a women’s issue. Washington (DC): NCPC, 1995 June: 34. 18. State and county activities. In: National Coalition of Physicians Against Family Violence Newsletter 1995;(spring):3. 19. Taylor S. In the spirit. Essence 1988;(Sept).

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BIBLIOGRAPHY

Adams D. Identifying the assaultive husband in court: you be the judge. Boston Bar J 1989;23. Browne A. When battered women kill. New York: The Free Press, 1987. Buel S, et al. Domestic violence: it can happen to anyone. Patient Care 1993;63. Buel S. Mandatory arrest for domestic violence. Harvard Womens Law J 1988;11:213. Campbell J, Sheridan D. Emergency nursing interventions with battered women. J Emerg Nurs 1989;15:12. Commonwealth of Massachusetts, Department of Public Health. Identifying and treating battered adult and adolescent women and their children: a guide for health care providers. 1992. Council on Ethical and Judicial Affairs, American Medical Association. Physicians and domestic violence, ethical considerations. JAMA 1992;267:3190. Council on Scientific Affairs, American Medical Association. Violence against women, relevance for medical practitioner. JAMA 1992;267:3184. Flitcraft A, Hadley S, et al. American Medical Association diagnostic and treatment guidelines on domestic violence, 1992. Flitcraft A. Battered women in your practice? Patient Care 1090;107. Fruend K, Blackhall LJ. Detection of domestic violence in a primary care setting. Clin Res 1990;38:738A. Jones A, Schechter S. When love goes wrong. Harper Collins, 1993. Jones R. Domestic violence: let our voices be heard. Obstet Gynecology 1993;81. King M, Perri M, Ryan J. Reaching out to battered women: a training manual for emergency department nurses. Stone Circle Press, 1987. Levy B (ed). Dating violence, young women in danger. The Seal Press, 1990. Lobe1 K (ed). Naming the violence, speaking out about lesbian battering. The Seal Press, 1986. McFarlane J. Battering during pregnancy: tip of an iceberg revealed. Women Health 1989;15:69. McHardy L, Hofford M (eds). Family violence, state of the art court practices. National Council of Juvenile and Family Court Judges, 1992. McKibbon L, DeVos E, Newberger E. Victimization of mothers of abused children. Pediatrics 1989;84:531-5. McLeer S, Anwar R. The role of the emergency physician in the prevention of domestic violence. Ann Emerg Med 1987;16:1155. Parker B, McFarlane J, Soeken K, Torres S, Campbell D. Physical and emotional abuse in pregnancy: a comparison of adult and teenage women. Nurs Res 1993;42:173. Parker B, McFarlane J. Identifying and helping battered pregnant women. 1991;16:161. Randall T. ACOG renews domestic violence campaign, calls for changes in medical school curricula. JAMA 1992;267:3131. Sugg N, Inui T. Primary care physicians’ response to domestic violence. JAMA 1992; 267:3157.

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PERSONAL Safety During an Explosive Incident l If an argument seems unavoidable, try to have it in a room or area where you have access to an exit. Try to stay away from the bathroom, kitchen, bedroom, or anywhere else where weapons might be available. l Practice how to get out of your home safely. Identify which doors, windows, elevator, or stairwell would be best. l Have a packed bag ready, and keep it at a relative’s or friend’s home in order to leave quickly. l Identify one or more neighbors you can tell about the violence, and ask that they call the police if they hear a disturbance coming from your home. l Devise a code word to use with your children, family, friends, and neighbors when you need the police. l Decide and plan for where you will go if you have to leave home (even if you don’t think you will need to). l Use your own instincts and judgment. If the situation is very dangerous, consider giving the abuser what he wants to calm him down. You have the right to protect yourself until you are out of danger. l Always remember: You don’t deserve to be hit or threatened! Safety When Preparing to Leave l Open a savings account and/or a credit card in your own name to start to establish or increase your independence. Think of other ways in which you can increase your independence. 0 Leave money, an extra set of keys, copies of important documents, extra medicines, and clothes with someone you trust so you can leave quickly.

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SAFETY PLAN:

APPENDIX *YOU HAVE A RIGHT

Determine who would be able to let you stay with them or lend you some money. l Keep the shelter or hotline phone number close at hand and keep some change or a calling card on you at all times for emergency phone calls. 0 Review your safety plan as often as possible in order to plan the safest way to leave your batterer. Remember: Leaving your batterer is the most dangerous time. l

Safety in Your Own Home l Change the locks on your doors as soon as possible. Buy additional locks and safety devices to secure your windows. l Discuss a safety plan with your children for when you are not with them. l Inform your children’s school, day care, etc, about who has permission to pick up your children. l Inform neighbors and landlord that your partner no longer lives with you and that they should call the police if they see him near your home. Safety with a Protective Order l Keep your protective order on you at all times. (When you change your purse, that should be the first thing that goes in it.) Give a copy to a trusted neighbor or family member. l Call the police if your partner breaks the protective order. l Think of alternative ways to keep safe if the police do not respond right away. l Inform family, friends, neighbors, and your physician or health care provider that you have a protective order in effect.

TO BE SAFE!

Safety on the Job and in Public l Decide who at work you will inform of your situation. This should include office or building security. Provide a picture of your batterer if possible. 0 Arrange to have an answering machine, caller ID, or a trusted friend or relative screen your telephone calls if possible. l Devise a safety plan for when you leave work. Have someone escort you to your car, bus, or train and wait with you until you are safely en route. Use a variety of routes to go home by if possible. Think about what you would do if something happened while going home (eg, in your car, on the bus, etc). Your Safety and Emotional Health l If you are thinking of returning to a potentially abusive situation, discuss an alternative plan with someone you trust. l If you have to communicate with your partner, determine the safest way to do so. l Have positive thoughts about yourself and be assertive with others about your needs. Read books, articles, and poems to help you to feel stronger. l Decide who you call to talk freely and openly to give you the support you need. l Plan to attend a women’s or victim’s support group for at least 2 weeks to gain support from others and learn more about yourself and the relationship. For Teens in a Violent Dating Relationship l Decide which friend, teacher, relative, or police officer you can tell. l Contact an advocate at the court to decide how to obtain a restraining order and make a safety plan.

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APPENDIX

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RESOURCES

CHECKLIST

For more information about your legal rights and options, contact an advocate at your local court or shelter or one of the following numbers BATTERED

WOMEN’S

SHELTERS

Casa Myrna Vasquez (24 hour) Transition House (24 hour) Renewal House Elizabeth Stone House Respond

(800) 992-2600 661-7203 566-6881 522-3417 623-5900

WHAT

Violence Unit

911 349-3370 625-1600 972-6500 484-1212 646-1000

MIDDLESEX COUNTY D .A.‘S OFFICE

Domestic Violence Unit (MAPP) Victim Witness Advocates Cambridge Division Malden Division Natick Division Newton Division Somerville Division Waltham Division Woburn Division OTHER

IMPORTANT

(617) 629-0222 (617) (508) (508) (617) (508) (617) (617)

Financial Money and/or credit cards Bank books Checkbooks

I’/2

in 1995 by the City of Cambridge,

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Legal papers Your restraining order Lease, rental agreement, house deed Car registration and insurance papers Health and life insurance papers Medical records for you and children School records Work permits/green card/visa Passport Divorce papers ___ Custody papers Other ~.

NUMBERS

Dating Violence Intervention Project Cambridge & Somerville Legal Services Cambridgeport Problem Center Fenway Community Health Center Network for Battered Lesbians Immigrant & Refugee Coalition Disabled Abuse Hotline (800) Elder Abuse Hotline (800) “Developed

4944430 322-2020 875-4141 964-6640 625-2521 893-7140 933-9586 868-8328 494-1800 661-1010 267-0900 424-8611 357-6000 426-9009 922-2275

YOU LEAVE

Identification Driver’s license Children’s birth certificates Your birth certificate Social security card Welfare identification

POLICE

Emergency Cambridge Domestic Somerville Police Watertown Police Belmont Police Arlington Police

YOU NEED TO TAKE WHEN

___ ____

House and car keys Medications Small saleable objects _ Jewelry Address book Phone card Pictures of you, children, and your abuser Children’s small toys Toiletries/diapers Change of clothes for you and your kids

Massachusetts.

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