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Overcoming Barriers to Physician Involvement in Identifying and Referring Victims of Domestic Violence
SPECIAL CONTRIBUTION
Overcoming Barriers to Physician Involvement in Identifying and Referring Victims of Domestic Violence Dr Gremillion is affiliated with the University of North Carolina School of Medicine and the Wake Medical C~ter Area Health Education Center. Dr Kanof is in private practice.
David H Gremillion, MD Elizabeth P Kanof, MD
Presented at the "Violence Against Women: Issues for Health Care Providers" symposium, Chapel Hill, North Carolina, October 1995. Copyright © by the American College of Emergency Physicians.
JUNE 1996 2 7 : 6 ANNALS OF EMERGENCY MEEUCINE
[Gremillion DH, Kanof EP: Overcoming barriers to physician involvement in identifying and referring victims of domestic violence. Ann EmergMedJune 1996;27:769-773.]
INTRODUCTION Domestic violence is common in our society 1 Although current reporting may underestimate the prevalence, most authorities agree that between 2 and 4 million incidents occur each year. 2 Victims often seek help in primary care clinics, physician's offices, and emergency care settings. 3 Physicians in these and other settings are uniquely positioned to be helpful. Their rapport with patients, the intimacy of communication with them, and their awareness of current and often past trauma can help reveal hidden cases. The time and effort may reveal a "battering syndrome" in which physical assault is followed by an increase in general medical symptoms and emotional problems. Abuse may be associated with depression, anxiety, psychologic disorders, drug and alcohol abuse, headache, chronic pain, and a variety of gastrointestinal disorders. Drossman et aP recently reported that the frequency of a history of rape or incest was 31% for patients with functional gastrointestinal disorders, compared with 18% for those with orgamc disorders. 4 Unfortunately, doctors seldom ask their patients directly about domestic violence, and even when they encounter evidence of domestic violence their written documentation is often lacking. 5 Recent investigations have clarified the barriers to meaningful involvement of physicians with their patient-victims. These barriers are complex and varied and range from past personal experiences to poor training (Figure). Patients want their physicians to routinely inquire about abuse. In one recent study, physicians were perceived as most helpful by 67% of victims, a proportion exceeded only by social workers and crisis counselors. 6 A survey of 164 patients at public and private clinics disclosed that 78% of respondents favored routine inquiry but that only 7% had ever been asked, r Several studies in emergency and
7 69
OVERCOMING BARRIERS Gremillion & Kanof
clinic settings (Table) document that doctors and nurses detect spousal abuse m only 10% to 50% of instances. Nevertheless, most physicians believe that they have much to offer and acknowledge that they should routinely screen for spouse abuse in their practicesS; they further unde> stand that their involvement can make an important difference. 9 A common concern voiced by doctors however, is a sense of inadequate training and support. SOCIETAL AND CULTURAL BARRLERS
Societal characteristics may increase the risk for family violence and at the same time impede physicians from interceding on the victim's behalf. Some researchers postulate that our social structure and ideology are conducive to domestic violence. Criminal violence and socially legitimate physical violence (punishment) are visible parts of contemporary culture. Violence permeates society through graphic media, movies, and television3 ° Physicians, like everyone, are susceptible to the resulting pervasive desensitization. Family norms contribute to the tolerance of domestic violence. Childhood experience with violence "legitimizes" violence of all types, but especially intrafamilial violence. By using physical pumshment, parents teach their children indirectly that love and violence, beneficence and pain are somehow fused. This projects a moral right to hit other family m e m b e r s According to one theory, domestic abuse Figure. Barriers to physician involvement in domestic violence. Contemporary social issues Societal tolerance of violence Desensitization through exposure Implicit and explicit social norms Power inequities in relationships
reflects and reinforces established historical hierarchies of inequity. ~1 Society's traditional support of male dominance in marriage may reinforce the husband's authority and the victim's powerlessness. On the other hand, violence in society and family relationships may be derived, at least in part, from the violent behavior of women. 12,13 Physicians may find it difficuh to believe that "normal" men and women can engage in secret brutality. Social norms suggest that intimate partners, being consenting adults, are responsible for their own experiences. This may explain society's tolerance of violence in intimate relationships even while it expresses outrage at the abuse of children and elders. 14 Many cultural beliefs threaten the physician's ability to correctly diagnose and treat victims of domestic violence. First, some professionals accept the notion that victims are responsible for the violence that is directed against them. 15 "Blaming the victim" is a common but subtle theme in contemporary society. Physicians may conclude that the victim's psychiatric makeup or personality led both to the abuse and to the inability to leave the relationship. It is possible that the cultural context in which physicians are raised makes them unlikely to recognize and assist in the problem of domestic violence. Physicians must explore and understand their personal concepts of power and control as a first step toward proriding appropriate care. Education and improved awareness of their own beliefs about victimization can afford physicians insight and sensitivity. 9 Once sensitized to risk factors for family violence, physicians are more likely to understand and recognize it. PROFESSIONAL BARRIERS
Professional deterrents to physician involvement are derived from the rigid nature of clinical practice, physi-
Personal factors Sex bias Personal history of abuse Idealized concepts of family life Privacy concerns Sense of powerlessness
Table. Studies documenting inadequate detection by physicians. Rate of Detection (%)
Professional factors Time constraints inadequate skills Professional relationship with abuser Professional detachment
Institutional and legal factors Fear of legal reprisal Limited institutional resources Inadequate or unclear policies Loss of insurance
770
Setting
Physician Retrospective Reference
ED unselected patients ED unselected patients ED unselected patients ED select sample of proven victims Community practice Community practice Community practice
2.8 5.6 5 18 1.5 8.5 4
16 30 22 100 22.7 17 16
ANNALS OF EMERGENCY MEDICINE 27:6
30 31 32 33 34 35 36
JUNE 1996
OVERCOMING BARRIERS d~'emillion & Kanof
clan misconceptions about patient wishes, confidentiality, and confusion about the proper role of medicine in domestic violence. Many doctors receive inadequate education in this area during medical school and postgraduate training. Physicians often say they do not have time to inquire about domestic violence. Competing clinical priorities and misconceptions about the real prevalence of violence in their practices create the impression that pursuing it is "not a good investment of time." In one study, 71% of physicians considered this the key deterrent. 16 Furthermore, the dialogue that follows the revelation of violence may be lengthy, open ended, and uncomfortable for physician and patient. Physicians often acknowledge that intervention may save time in the long run, but they have trouble incorporating this prevention-minded concept into the context of a given clinical encounter. In the cost-conscious era of managed care, time may become an even greater limiting factor. Medical schools and primary care training programs devote limited attention to training. In 1989, only 47% of medical schools offered programs of instruction in this area. ~r The mean number of sessions was 1.5, and the mean number of hours per session was 1.9. Only 8% of physicians in one study responded that they had received good training about domestic violence. 16 Another recent study of 1,521 practicing clinicians from various disciplines documented that more than one third had received no education about child, elder, or spouse abuse, ss In many communities, the physician may have a professional relationship with the abuser as well as the abused. The wish to serve as dual advocate can have a paralyring effect. Inaction by a physician who is caring for both partners may have the unfortunate effect of reinforcing the abusive relationship and increasing the violence. The model of the doctor as a detached and objective observer may devalue and even discourage intuitive and emotional input in clinical encounters. This model has served to protect physicians from the awareness of their own feelings and those of their patients, s9 The pattern of disciplined thinking, although effective in clinic crises and diagnostic challenges, is a formidable barrier to recognition of abuse. Lack of acknowledgment contributes to the victim's cycle of disempowerment and loss of control. In many ways, the traditional doctorpatient relationship duplicates the power and control dynamics of the battering relationship and risks revictimizing the abuse victim. Although most patients want physicians to address the issue of domestic violence, physicians often perceive
JUNE 1996
27:6
ANNALS OF EMERGENCY MEDICINE
patients to be cool to such inqui W. Physicians express concern that appearing to accuse the partner or to nose into private matters is a potential threat to an otherwise positive physician-patient relationship. The privacy of the physician-patient relationship may pose obstacles to open physician involvement. Time-honored principles of confidentiality and patient autonomy give the patient a right to privacy and to selfdetermination about disclosure. 2° This may place the physician in the difficult position of advocating for the patient despite her wish for privacy. The professional deterrents that physicians encounter are derived from lack of awareness, sensitivity, and training. Inadequate attention to domestic violence in medical schools produces graduates whose index of suspicion and basic skills are limited. Curricula should cover the broad spectrum of violence in society and its relevance to the health care needs of patients. Practicing physicians need continuing medical education courses developed to address their deficiencies of information and skills necessary to serve abused patients. Annual courses should routinely incorporate domestic violence as a presentation theme. PERSONAL BARRIERS
Personal attitudes and experiences may contribute to lack of recognition and referral. Physicians identify with patients of similar backgrounds, and this may lead to false assumptions. As a result, domestic violence may be left off the differential diagnosis list. s Many physicians have had a personal experience of abusing or being abused. They may fail to make the diagnosis of abuse to avoid personal discomfort. Sugg and Inui found that 31% of female and 14% of male physicians in their study group acknowledged previous abuse. ~6 Some physicians hold back because they regard inquiry as an invasion of personal space. 21 This attitude contrasts with the ease with which they inquire about other areas of patients' private lives. Inquiring physicians risk uncovering moral or criminal violations of the traditional ideals of family life. Physicians may inappropriately try to preserve family "integrity" by denying the diagnosis of domestic violence. They may invoke the right of family privacy to justify their position that violence should be resolved within a relationship that is protected from the ethical codes and laws that govern the public sphere, s6 This is a dangerous course for victims because escalation usually occurs if the cycle of violence is not interrupted.
771
OVERCOMING BARRIERS GremilIion & Kanof
To identify domestic abuse, physicians must realize that abusive behavior is both a public and a private injustice. A physician's sex may in part determine attitude toward victims of domestic violence. 22 Some female physicians avoid diagnosing victimization among their female patients. They may identify with them and fear facing their own feelings of vulnerability and lack of control. Denial serves as an emotional shield and is a barrier to truth. This protective mechanism is most common with white, middle- to upper-class patients, reflecting the racial and socioeconomic status of most female physicians. Women physicians are more likely than men to be empathic toward victims of domestic violence and less likely to blame them, in part because they feel greater risk than men. 23 Patients are more likely to disclose information to women, but most doctors are male, which negatively influences the likelihood of disclosure. 24 Male physicians are less interested in the issue of domestic violence than are female physicians. 25 They hesitate to become involved because they believe that victims do not want to discuss the issue. 26 However, male physicians can have great impact by validating a woman's experience and speaking out against male violence toward women. Another factor that influences the effectiveness of physician intervention is that physicians identify themselves as problem-solvers. They are frustrated by their perceived powerlessness and loss of control when managing cases of domestic violence. These feelings of inadequacy are attributable to the recurrent nature of domestic violence and the fact that patients are ultimately responsible for their own cure. Physicians can lessen their discomfort if they recognize that their role is as validator, listener, and advisor. Physicians must avoid the pitfall of "rescuing" patients because this only sabotages the critical work that the patient must accomplish independently. The patient must reclaim a sense of control and determination to achieve desired life changes. 2r Physicians can overcome the personal impediments to involvement through education and experience. Personal barriers, fears, and misconceptions are surmountable. At the least, if physicians recognize the prevalence of and learn about the natural history of domestic violence, their reasons for avoiding the issue will seem less important. Physicians can become comfortable with diagnosis, referral, and even specific counseling goals and techniques; they will find their fears diminish in comparison with the newly attained goals of rehabilitation and restoration of the self-esteem and personal productivity of their patients.
7 72.
INSTITUTIONAL AND LEGAL BARRIERS
Even if personal mechanisms allow effective discourse with a victim, physicians may confront substantial institutional barriers. These relate to lack of personnel, space, or policy Administrative pressure for "productivity" may preclude the type of reflective and thoughtful communication that leads to disclosure of stigmatizing clinical issues such as spouse abuse. After a disclosure has occurred, there may be a gantlet of administrative procedures, limited institutional capacities, and inefficiencies. Unlike other clinical conditions for which there are clear diagnostic and therapeutic guidelines, the disclosure of spousal abuse leads to no such dear pathways. The timing of violent acts and the arrival of patients in the emergency department may prevent a smooth transition to proper care. In 1991, the Joint Commission on Accreditation of Healthcare Organizations mandated that EDs maintain domestic violence protocols. 2s Despite this, a recent survey disclosed that 46% had none. 29 When they do exist, such protocols may be inadequate or not properly updated with current numbers and contacts. Inadequate shelter capacity is a common deterrent to referral. Nationwide, only two of five candidates can be accommodated in shelters. Also, the external scrutiny of hospital admissions may prevent use of admission as a strategy to protect patients. To properly address institutional barriers, there must be an organizational commitment to reducing them. Protocols should be available, current, and functional. Hospitals that have a high frequency of domestic violence cases should hire nurse clinicians or social workers as resources for intervention and protocol maintenance. Fear of "legal entanglement" may deter physicians. In addition to the potential of time commitment as a witness, physicians often cite vulnerability to civil action by the abuser or even the abused. Many experts note that such concerns are not well founded and are surely balanced by concern about liability for failing to diagnose and document. Even with seemingly innocuous statements in the medical records, insurance companies may deny coverage to victims of domestic violence by calling it a "preexisting" or "high-risk" condition. Physicians may be reluctant to compromise a vulnerable patient's health care coverage. A domestic violence task force or committee that analyzes and strengthens available referral resources and community resources is a strong asset. Hospital-based domestic violence intervention programs have been successful at many sites by providing ready access to welltrained practitioners. Because recognition of domestic violence may occur throughout all levels of the health
ANNALS OF EMERGENCY MEDICINE 2 7 : 6 JUNE 1996
OVERCOMING
BARRIERS
Gremdlion & Kanof
care system, it is important to conduct regular educational sessions among nursing staff and other hospital personnel. CONCLUSION
Physicians have a major rote in the complex issues of violence in society, families, and intimate partnerships. The clinical and economic dimensions of domestic violence demand that we incorporate these concepts into undergraduate and graduate training programs. By analyzing our attitudes about violence in general and our clinical encounters in particular, we can strengthen our response. We must become familiar with the personal, professional, societal, and institutional barriers that impede that response. These barriers must be addressed by society, by our professional schools, and by each of us in the context of our personal and professional lives. REFERENCES 1. Straus MA, Gelles 8J: Societal change and change in family violence from 1975to 1985as revealed by two national surveys. J Marriage Fam1986748:465-479. 2. McCauleyJ, Darn DE, KolodnerK, et ak The "battering syndrome":Prevalenceand clinica) characteristics of domesticviolence in primary care internal medicine practices.Ann InternMed 19957123:734-746. 3. Abbott J, Johnson R, KozioI-McLainJ, et ab Domesticviolenceagainst women: incidence and prevalence in an emergencydepartmentpopulation. JAMA 1995;273:1763-1767. 4. DressmanDA, Talley NJ, LesermanJ, et al: Sexual and physical abuse and gastrointestinal illness: Reviewand recommendations.Ann InternMad 1995;123:782-794, 5 Lamb S: Acts without agents:An analysis of linguistic avoidancein journal articles on men who batter women. Am J Orthopsychiatry1991761:250-257. 6. Hamilton B, CoatesJ: Perceivedhelpfulness and use of professionalservices by abused women. J Fam Vio1199378:. 7. FriedmanLS, SametJH, RobertsMS, et el: Inquiry about victimization experiences:A survey of patient preferencesand physician practices.Arch InternMed1992;152:1186-1190. 8. EestealPW, EastealS: Attitudes and practices of doctors toward spouseassault victims: An Australian study, Violence Vict199277:217-228:8-13.
18. Tilden VP, SchmidtTA, l_imandri BJ, et ah Factorsthat influence clinicians' assessmentand managementof family violence. Am J PublicHealth 1994;84:628-633. 19. RandallT: Domesticviolence intervention calls for more than treating injuries. JAMA 1990;264:939-940. 20. Council on Ethical and Judicial Affairs, American Medical Association: Physiciansand domestic violence: Ethical considerations.JAMA 19927267:3190. 21. Jecker NS: Privacybeliefs and the violent family: Extendingthe ethical argumentfor physician intervention. JAMA 1993;269:776-780. 22. SaundersDG, Kindy P: Predictorsof physicians' responseto woman abuse:The role of gender, background,and brief training, J GanInternMad 1993;8:606-609. 23. RoseK, SaundersDG: Nurses' and physicians' attitudes about women abuse:The effects of gender and professional role. Health Care WomenInt 1986;7:427-438. 24. NewbergerEH, BarkanSE, LiebermanED, et ah Abuse of pregnantwomen and adversebirth outcome:Currentknowledgeand implications for practice. JAMA 1992;267:2370. 25. KellermannAL: DomesticviNence and the internist's response:Advocacyor apathy? J Gen InternMad 1990;5:89-90. 26. BrownJB, Lent B, Sas G: identi~ing and treating wife abase. J FaroPract1993736:185-191. 27. Sassetti MR: Domesticviolence. Prim Care1993;20:289-305. 28. Joint Commissionon Accreditationof HealthcareOrganizations:AccreditationManualfor Hospitals: Vet 1. Standards OakbrookTerrace, IL, Joint Commissionell Accreditationof Hea/thcareOrganizations,1992:21-22. 29. Emergencydepartment responseto domesticviolence--California, 1992. MMWRMorb Mortal WklyRep 1993742:617-620. 30. Stark E, Flitcraft A, FraizerW: Medicine and patriarchal violence:The social constructionof a "private" event, lot J Health Serv1979;93:461-493. 31. Mckeer SV, Anwar RA, HermanS, et ah Education is nat enough:A systemsfailure in protecting batteredwomen.Ann EmergMad 1989;18:651-653. 32. GoldbergWG, Tomlanevich MC: Domesticviolence victims in the emergencydepartment: Now findings. JAMA 1984;251:3259-3264. 33. BergmanB, BrismarB: Batteredwives: Measureby the social and medical services. Pestered Med J 1990766:28-33. 34. HambergerLK, SaundersDG, HoveyM: Prevalenceof domestic violence in communitypractice and rate of physician inquiry FaroMarl 1992;24:283-287. 35. Ferris LE,Tudiver F: Familyphysicians' approachto wife abuse:A study of Ontario,Canada, practices. FernMad 1992;24:276-282. 36. Rath GD, Jarratt LG, LeonardsonGL: Ratesof domesticviolence against adult women by men partners. J Am BoardFaroPract1889;2:227-233.
Reprint no. 47/1/72733 Reprints not available from the authors.
9. McAfee RM: Physiciansand domesticviolence: Can we make a difference? JAMA 199571273:1790-1791. 10. Straus MA, Smith C: Family patternsand primary preventionof family violence. Trends Health CareLaw Ethics1993;8: 17-25. 11. Pulgn KJ, CosgroveA: Empoweringphysiciansto respondto domesticviolence. Wis Mad J 1992;91:288-283. 12. Straus MA. Physical assaults by wives: A major social problem, in Gelles RJ, LosekeDR (eds}: Currentcontreversiesen family violence. Newbury Park,CA: SagePublications, 1993:67~87. 13. White JW, Kowalski RM: Oeconstructingthe myth of the non-aggressivewoman. Psych WomenQ 1991;19:487-508. 14. Tilden VP: Responseef the health care degverysystemto battered women. IssuesMeet Health Nurs1989710:309-320. 15. Burge SK: Violenceagainst women as a health care issue. FaroMeal1989721:388-373. 16. Sugg NK, Inui T: Primarycare physicians' responseto domesticviolence: Openie9Pandora's box. JAMA 19927267:3157-3160. 17. Educationabout adult domesticviolence in US and Canadianmedical schools, 1987 1988. MMWR Morb Mortal WklyRap 1989798:17-19.
JUNE 1996
2 7 : 8 ANNALS OF EMERGENCY MEDICINE
773
Overcoming Barriers to Physician Involvement in Identifying and Referring Victims of Domestic Violence Dr Gremillion is affiliated with the University of North Carolina School of Medicine and the Wake Medical C~ter Area Health Education Center. Dr Kanof is in private practice.
David H Gremillion, MD Elizabeth P Kanof, MD
Presented at the "Violence Against Women: Issues for Health Care Providers" symposium, Chapel Hill, North Carolina, October 1995. Copyright © by the American College of Emergency Physicians.
JUNE 1996 2 7 : 6 ANNALS OF EMERGENCY MEEUCINE
[Gremillion DH, Kanof EP: Overcoming barriers to physician involvement in identifying and referring victims of domestic violence. Ann EmergMedJune 1996;27:769-773.]
INTRODUCTION Domestic violence is common in our society 1 Although current reporting may underestimate the prevalence, most authorities agree that between 2 and 4 million incidents occur each year. 2 Victims often seek help in primary care clinics, physician's offices, and emergency care settings. 3 Physicians in these and other settings are uniquely positioned to be helpful. Their rapport with patients, the intimacy of communication with them, and their awareness of current and often past trauma can help reveal hidden cases. The time and effort may reveal a "battering syndrome" in which physical assault is followed by an increase in general medical symptoms and emotional problems. Abuse may be associated with depression, anxiety, psychologic disorders, drug and alcohol abuse, headache, chronic pain, and a variety of gastrointestinal disorders. Drossman et aP recently reported that the frequency of a history of rape or incest was 31% for patients with functional gastrointestinal disorders, compared with 18% for those with orgamc disorders. 4 Unfortunately, doctors seldom ask their patients directly about domestic violence, and even when they encounter evidence of domestic violence their written documentation is often lacking. 5 Recent investigations have clarified the barriers to meaningful involvement of physicians with their patient-victims. These barriers are complex and varied and range from past personal experiences to poor training (Figure). Patients want their physicians to routinely inquire about abuse. In one recent study, physicians were perceived as most helpful by 67% of victims, a proportion exceeded only by social workers and crisis counselors. 6 A survey of 164 patients at public and private clinics disclosed that 78% of respondents favored routine inquiry but that only 7% had ever been asked, r Several studies in emergency and
7 69
OVERCOMING BARRIERS Gremillion & Kanof
clinic settings (Table) document that doctors and nurses detect spousal abuse m only 10% to 50% of instances. Nevertheless, most physicians believe that they have much to offer and acknowledge that they should routinely screen for spouse abuse in their practicesS; they further unde> stand that their involvement can make an important difference. 9 A common concern voiced by doctors however, is a sense of inadequate training and support. SOCIETAL AND CULTURAL BARRLERS
Societal characteristics may increase the risk for family violence and at the same time impede physicians from interceding on the victim's behalf. Some researchers postulate that our social structure and ideology are conducive to domestic violence. Criminal violence and socially legitimate physical violence (punishment) are visible parts of contemporary culture. Violence permeates society through graphic media, movies, and television3 ° Physicians, like everyone, are susceptible to the resulting pervasive desensitization. Family norms contribute to the tolerance of domestic violence. Childhood experience with violence "legitimizes" violence of all types, but especially intrafamilial violence. By using physical pumshment, parents teach their children indirectly that love and violence, beneficence and pain are somehow fused. This projects a moral right to hit other family m e m b e r s According to one theory, domestic abuse Figure. Barriers to physician involvement in domestic violence. Contemporary social issues Societal tolerance of violence Desensitization through exposure Implicit and explicit social norms Power inequities in relationships
reflects and reinforces established historical hierarchies of inequity. ~1 Society's traditional support of male dominance in marriage may reinforce the husband's authority and the victim's powerlessness. On the other hand, violence in society and family relationships may be derived, at least in part, from the violent behavior of women. 12,13 Physicians may find it difficuh to believe that "normal" men and women can engage in secret brutality. Social norms suggest that intimate partners, being consenting adults, are responsible for their own experiences. This may explain society's tolerance of violence in intimate relationships even while it expresses outrage at the abuse of children and elders. 14 Many cultural beliefs threaten the physician's ability to correctly diagnose and treat victims of domestic violence. First, some professionals accept the notion that victims are responsible for the violence that is directed against them. 15 "Blaming the victim" is a common but subtle theme in contemporary society. Physicians may conclude that the victim's psychiatric makeup or personality led both to the abuse and to the inability to leave the relationship. It is possible that the cultural context in which physicians are raised makes them unlikely to recognize and assist in the problem of domestic violence. Physicians must explore and understand their personal concepts of power and control as a first step toward proriding appropriate care. Education and improved awareness of their own beliefs about victimization can afford physicians insight and sensitivity. 9 Once sensitized to risk factors for family violence, physicians are more likely to understand and recognize it. PROFESSIONAL BARRIERS
Professional deterrents to physician involvement are derived from the rigid nature of clinical practice, physi-
Personal factors Sex bias Personal history of abuse Idealized concepts of family life Privacy concerns Sense of powerlessness
Table. Studies documenting inadequate detection by physicians. Rate of Detection (%)
Professional factors Time constraints inadequate skills Professional relationship with abuser Professional detachment
Institutional and legal factors Fear of legal reprisal Limited institutional resources Inadequate or unclear policies Loss of insurance
770
Setting
Physician Retrospective Reference
ED unselected patients ED unselected patients ED unselected patients ED select sample of proven victims Community practice Community practice Community practice
2.8 5.6 5 18 1.5 8.5 4
16 30 22 100 22.7 17 16
ANNALS OF EMERGENCY MEDICINE 27:6
30 31 32 33 34 35 36
JUNE 1996
OVERCOMING BARRIERS d~'emillion & Kanof
clan misconceptions about patient wishes, confidentiality, and confusion about the proper role of medicine in domestic violence. Many doctors receive inadequate education in this area during medical school and postgraduate training. Physicians often say they do not have time to inquire about domestic violence. Competing clinical priorities and misconceptions about the real prevalence of violence in their practices create the impression that pursuing it is "not a good investment of time." In one study, 71% of physicians considered this the key deterrent. 16 Furthermore, the dialogue that follows the revelation of violence may be lengthy, open ended, and uncomfortable for physician and patient. Physicians often acknowledge that intervention may save time in the long run, but they have trouble incorporating this prevention-minded concept into the context of a given clinical encounter. In the cost-conscious era of managed care, time may become an even greater limiting factor. Medical schools and primary care training programs devote limited attention to training. In 1989, only 47% of medical schools offered programs of instruction in this area. ~r The mean number of sessions was 1.5, and the mean number of hours per session was 1.9. Only 8% of physicians in one study responded that they had received good training about domestic violence. 16 Another recent study of 1,521 practicing clinicians from various disciplines documented that more than one third had received no education about child, elder, or spouse abuse, ss In many communities, the physician may have a professional relationship with the abuser as well as the abused. The wish to serve as dual advocate can have a paralyring effect. Inaction by a physician who is caring for both partners may have the unfortunate effect of reinforcing the abusive relationship and increasing the violence. The model of the doctor as a detached and objective observer may devalue and even discourage intuitive and emotional input in clinical encounters. This model has served to protect physicians from the awareness of their own feelings and those of their patients, s9 The pattern of disciplined thinking, although effective in clinic crises and diagnostic challenges, is a formidable barrier to recognition of abuse. Lack of acknowledgment contributes to the victim's cycle of disempowerment and loss of control. In many ways, the traditional doctorpatient relationship duplicates the power and control dynamics of the battering relationship and risks revictimizing the abuse victim. Although most patients want physicians to address the issue of domestic violence, physicians often perceive
JUNE 1996
27:6
ANNALS OF EMERGENCY MEDICINE
patients to be cool to such inqui W. Physicians express concern that appearing to accuse the partner or to nose into private matters is a potential threat to an otherwise positive physician-patient relationship. The privacy of the physician-patient relationship may pose obstacles to open physician involvement. Time-honored principles of confidentiality and patient autonomy give the patient a right to privacy and to selfdetermination about disclosure. 2° This may place the physician in the difficult position of advocating for the patient despite her wish for privacy. The professional deterrents that physicians encounter are derived from lack of awareness, sensitivity, and training. Inadequate attention to domestic violence in medical schools produces graduates whose index of suspicion and basic skills are limited. Curricula should cover the broad spectrum of violence in society and its relevance to the health care needs of patients. Practicing physicians need continuing medical education courses developed to address their deficiencies of information and skills necessary to serve abused patients. Annual courses should routinely incorporate domestic violence as a presentation theme. PERSONAL BARRIERS
Personal attitudes and experiences may contribute to lack of recognition and referral. Physicians identify with patients of similar backgrounds, and this may lead to false assumptions. As a result, domestic violence may be left off the differential diagnosis list. s Many physicians have had a personal experience of abusing or being abused. They may fail to make the diagnosis of abuse to avoid personal discomfort. Sugg and Inui found that 31% of female and 14% of male physicians in their study group acknowledged previous abuse. ~6 Some physicians hold back because they regard inquiry as an invasion of personal space. 21 This attitude contrasts with the ease with which they inquire about other areas of patients' private lives. Inquiring physicians risk uncovering moral or criminal violations of the traditional ideals of family life. Physicians may inappropriately try to preserve family "integrity" by denying the diagnosis of domestic violence. They may invoke the right of family privacy to justify their position that violence should be resolved within a relationship that is protected from the ethical codes and laws that govern the public sphere, s6 This is a dangerous course for victims because escalation usually occurs if the cycle of violence is not interrupted.
771
OVERCOMING BARRIERS GremilIion & Kanof
To identify domestic abuse, physicians must realize that abusive behavior is both a public and a private injustice. A physician's sex may in part determine attitude toward victims of domestic violence. 22 Some female physicians avoid diagnosing victimization among their female patients. They may identify with them and fear facing their own feelings of vulnerability and lack of control. Denial serves as an emotional shield and is a barrier to truth. This protective mechanism is most common with white, middle- to upper-class patients, reflecting the racial and socioeconomic status of most female physicians. Women physicians are more likely than men to be empathic toward victims of domestic violence and less likely to blame them, in part because they feel greater risk than men. 23 Patients are more likely to disclose information to women, but most doctors are male, which negatively influences the likelihood of disclosure. 24 Male physicians are less interested in the issue of domestic violence than are female physicians. 25 They hesitate to become involved because they believe that victims do not want to discuss the issue. 26 However, male physicians can have great impact by validating a woman's experience and speaking out against male violence toward women. Another factor that influences the effectiveness of physician intervention is that physicians identify themselves as problem-solvers. They are frustrated by their perceived powerlessness and loss of control when managing cases of domestic violence. These feelings of inadequacy are attributable to the recurrent nature of domestic violence and the fact that patients are ultimately responsible for their own cure. Physicians can lessen their discomfort if they recognize that their role is as validator, listener, and advisor. Physicians must avoid the pitfall of "rescuing" patients because this only sabotages the critical work that the patient must accomplish independently. The patient must reclaim a sense of control and determination to achieve desired life changes. 2r Physicians can overcome the personal impediments to involvement through education and experience. Personal barriers, fears, and misconceptions are surmountable. At the least, if physicians recognize the prevalence of and learn about the natural history of domestic violence, their reasons for avoiding the issue will seem less important. Physicians can become comfortable with diagnosis, referral, and even specific counseling goals and techniques; they will find their fears diminish in comparison with the newly attained goals of rehabilitation and restoration of the self-esteem and personal productivity of their patients.
7 72.
INSTITUTIONAL AND LEGAL BARRIERS
Even if personal mechanisms allow effective discourse with a victim, physicians may confront substantial institutional barriers. These relate to lack of personnel, space, or policy Administrative pressure for "productivity" may preclude the type of reflective and thoughtful communication that leads to disclosure of stigmatizing clinical issues such as spouse abuse. After a disclosure has occurred, there may be a gantlet of administrative procedures, limited institutional capacities, and inefficiencies. Unlike other clinical conditions for which there are clear diagnostic and therapeutic guidelines, the disclosure of spousal abuse leads to no such dear pathways. The timing of violent acts and the arrival of patients in the emergency department may prevent a smooth transition to proper care. In 1991, the Joint Commission on Accreditation of Healthcare Organizations mandated that EDs maintain domestic violence protocols. 2s Despite this, a recent survey disclosed that 46% had none. 29 When they do exist, such protocols may be inadequate or not properly updated with current numbers and contacts. Inadequate shelter capacity is a common deterrent to referral. Nationwide, only two of five candidates can be accommodated in shelters. Also, the external scrutiny of hospital admissions may prevent use of admission as a strategy to protect patients. To properly address institutional barriers, there must be an organizational commitment to reducing them. Protocols should be available, current, and functional. Hospitals that have a high frequency of domestic violence cases should hire nurse clinicians or social workers as resources for intervention and protocol maintenance. Fear of "legal entanglement" may deter physicians. In addition to the potential of time commitment as a witness, physicians often cite vulnerability to civil action by the abuser or even the abused. Many experts note that such concerns are not well founded and are surely balanced by concern about liability for failing to diagnose and document. Even with seemingly innocuous statements in the medical records, insurance companies may deny coverage to victims of domestic violence by calling it a "preexisting" or "high-risk" condition. Physicians may be reluctant to compromise a vulnerable patient's health care coverage. A domestic violence task force or committee that analyzes and strengthens available referral resources and community resources is a strong asset. Hospital-based domestic violence intervention programs have been successful at many sites by providing ready access to welltrained practitioners. Because recognition of domestic violence may occur throughout all levels of the health
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care system, it is important to conduct regular educational sessions among nursing staff and other hospital personnel. CONCLUSION
Physicians have a major rote in the complex issues of violence in society, families, and intimate partnerships. The clinical and economic dimensions of domestic violence demand that we incorporate these concepts into undergraduate and graduate training programs. By analyzing our attitudes about violence in general and our clinical encounters in particular, we can strengthen our response. We must become familiar with the personal, professional, societal, and institutional barriers that impede that response. These barriers must be addressed by society, by our professional schools, and by each of us in the context of our personal and professional lives. REFERENCES 1. Straus MA, Gelles 8J: Societal change and change in family violence from 1975to 1985as revealed by two national surveys. J Marriage Fam1986748:465-479. 2. McCauleyJ, Darn DE, KolodnerK, et ak The "battering syndrome":Prevalenceand clinica) characteristics of domesticviolence in primary care internal medicine practices.Ann InternMed 19957123:734-746. 3. Abbott J, Johnson R, KozioI-McLainJ, et ab Domesticviolenceagainst women: incidence and prevalence in an emergencydepartmentpopulation. JAMA 1995;273:1763-1767. 4. DressmanDA, Talley NJ, LesermanJ, et al: Sexual and physical abuse and gastrointestinal illness: Reviewand recommendations.Ann InternMad 1995;123:782-794, 5 Lamb S: Acts without agents:An analysis of linguistic avoidancein journal articles on men who batter women. Am J Orthopsychiatry1991761:250-257. 6. Hamilton B, CoatesJ: Perceivedhelpfulness and use of professionalservices by abused women. J Fam Vio1199378:. 7. FriedmanLS, SametJH, RobertsMS, et el: Inquiry about victimization experiences:A survey of patient preferencesand physician practices.Arch InternMed1992;152:1186-1190. 8. EestealPW, EastealS: Attitudes and practices of doctors toward spouseassault victims: An Australian study, Violence Vict199277:217-228:8-13.
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