- Email: [email protected]
Project SAFE: Domestic violence education for practicing physicians
Project SAFE: Domestic Violence Education for Practicing Physicians Anne Flitcraft,
MD
Associate Professor of Medicine Co-director, Domestic Violence Training Project University of Connecticut Health Center Farmington, Connecticut
F
or more than a decade, domestic violence advocates and health care providers have recognized that education of physicians about domestic violence is a key to the development of a comprehensive health care response to battered women. Every surgeon general since Dr. C. Everett Koop has identified family violence as a major health problem and has called upon researchers and clinicians alike to become a part of the solution. With the growth of the National Center for Injury Prevention and Control at the Centers for Disease Control and an emerging emphasis upon research in family violence, there has been a virtual explosion in knowledge regarding the epidemiology and health consequences of domestic violence. Initial prevalence estimates suggest that at least one adult woman in five will be physically assaulted by her partner. In clinical settings, 22%-35% of injured women presenting to emergency services are abused by partners, 23% of women seen in a family practice clinic and 14% of those in a university internal medicine clinic are in violent relationships, and 17% of obstetrical patients are assaulted during their pregnancy.i” Such figures stand in sharp contrast to rates of domestic violence identified routinely by physicians in these settings. The consistent failure to identify domestic violence in clinical practice has led to an emphasis on protocols and education as tools to help physicians address domestic violence in clinical evaluations. Nevertheless, the task of educating practicing physicians has proved difficult. In one of the first evaluations of a domestic violence protocol, McLeer et al successfully increased the rate of identification of abuse in an emergency department from 5.6% to 30% of female trauma patients. However, upon follow-up evaluation at the same site, rates of identification had dropped back to 7.7%, not significantly different than the baseline rate of identification.4 Kurz and Stark provide a more descriptive evaluation in their study of encounters between battered women and medical staff in a Philadelphia emergency department. They found that in the absence of an onsite advocate, clinicians tended to dismiss abused women as “evasive” and “repeaters” who will “just return home anyway.“5 What are the barriers to changing physicians’ approach to victims of domestic violence? Many barriers to physician education have been identi-
Women’s
Health
Issues
Vol.
5. No.
4 Winter
1995
Q 1995 by The Jacobs
Institute
of
~~~$$$~s SSDI
1049-3867(95)
00052.6
FLITCRAFT:
PROJECT
SAFE
183
fied. McLeer et al conclude that “without institutional policies and procedures for detecting and treating victims of domestic violence, many abused women will pass through unidentified and hence, untreated.“4 Warshaw has characterized barriers within the traditional medical model and in physicians’ ambiguity about abuse of power and control in personal relationships.6 Sugg and Innui identify physicians’ fear of offending patients, sense of powerlessness, and concern over disruptions in schedules as additional barriers that inhibit change in practice standards.7 Connecticut’s Domestic Violence Training Project, founded in 1985 under the state’s Family Violence Prevention and Response Act, is one of the nation’s first programs dedicated to providing domestic violence education for health care providers. Nationally recognized for its interdisciplinary educational programs and technical assistance to hospitals, clinics, and professional organizations, the Domestic Violence Training Project has involved more than 10,000 health care providers in the past decade. During this period, physicians were rare participants in training and educational programs on domestic violence. Our experience with physicians is shared by others in the field, including New York State’s Office for the Prevention of Domestic Violence, founded in 1989. Access to physician audiences has been limited and problematic for many involved in domestic violence educational efforts. In the face of such barriers to educating practicing physicians, more recent initiatives have emphasized the importance of educating medical students about domestic violence. The Domestic Violence Identification and Referral Act, for instance, proposed linking funding of medical schools to implementation of domestic violence curricular reform. The AAMC hosted a consensus conference to identify model undergraduate family violence curricula and strategies for incorporating family violence education into medical school programs. As discussed at this conference, significant efforts to educate medical students and residents are now underway. From The Doctoring Curriculum at the University of California, Los Angeles, to the Primary Care Clerkship at the University of Connecticut, a significant minority of medical students now receive-in core courses or electives-some basic information on domestic violence. Residency programs are undergoing similar change. The Society of Teachers of Family Medicine, in a survey conducted in 1989, found that 41% of programs had at least “some” family violence education and that fully 28% more were planning to expand this content in the curriculum.8 Chambliss, Bay, and Jones report that 28% of ob/gyn residency programs surveyed teach residents to ask all or almost all patients about domestic violence and employ an obstetrician/gynecologist with expertise in domestic violence. Fully 60% of the residency programs were not satisfied with their current curricula, and 70% indicated a need for help in developing or improving their domestic violence curricula.9 All of these authors acknowledge that the figures demonstrate the need for continued curricular development. Nevertheless, the current situation is, in all likelihood, a dramatic improvement from a decade ago, and as Chambliss’ data suggest, we can anticipate that the rate of change will continue. What are the limits of undergraduate and residency training? As the student/young physician advances through education, training, and subspecialty training, the role of the attending physician becomes paramount. The best efforts of the basic sciences faculty are ephemeral unless reinforced and exemplified in the practices of the clinical faculty. As medical education moves from the classroom and hospital to ambulatory care setting, practicing physicians-as attendings and community preceptors-assume an even more important role in the development of young physicians’ practice patterns. Access to attending physicians proves difficult, and changing attendings’ 184
FLITCRAFT:
PROJECT
SAFE
Women’s
Health
Issues
Vol.
5, No.
4 Winter
1995
clinical practice is particularly challenging. But advances in medical education curricula as well as residency training will be blunted unless domestic violence identification and interventions are modeled by attending staff. Continuing medical education thus emerges as an important key in the efforts to change physicians’ response to domestic violence and to incorporate physicians into community-wide domestic violence intervention and prevention efforts. Continuing medical education has been a major project of the professional organizations as they turn attentions to domestic violence. Since 1984, The American College of Obstetricians and Gynecologists (ACOG) has maintained materials, guidelines, and educational seminars on domestic violence for practicing obstetrician/gynecologists. Domestic violence is featured prominently in the American Medical Association (AMA) campaign on family violence, directed specifically to practicing physicians. Indeed, in the wake of the AMA initiative, nearly half of all state medical societies have created task forces, developed protocols, or sponsored recent educational programs on family violence. Many state societies, including those in Massachusetts, Oklahoma, Minnesota, and Ohio, have produced physician handbooks and patient educational materials that provide information and a listing of statewide community services for battered women and their families.” The American Women’s Medical Association’s Advanced Curriculum on Women’s Health and the annual meetings of the American College of Emergency Physicians, American Academy of Family Physicians, and many other medical societies now regularly feature speakers and workshops on domestic violence at annual meetings. In fact, professional organizations have provided the mainstay of clinical activism on this issue. In contrast to the successful activities at the national and state levels, it remains difficult to attract physicians to local interdisciplinary domestic violence conferences. Domestic violence conferences held at hospitals generally include few physicians and physician continuing medical education (CME) tends to be an activity separate from the educational activities of nursing, social work, and administrative staff. However, Dr. Richard Jones of Hartford, Connecticut, was successful in 1993 in translating his own attention to domestic violence as president of ACOG to his local community.
A MODEL
LOCAL
CME
PROGRAM:
PROJECT
SAFE
Project SAFE was implemented in Hartford, Connecticut, in 1993. The target audience for this educational program on domestic violence was the practicing physicians at the five hospitals in Hartford County, Connecticut. The project’s goal was to enhance the health care response to battered women in the Hartford region by encouraging physicians to provide Safety Assessment for Everyone. The specific activities of Project SAFE included grand rounds presentations in various specialties within each of the hospitals and distribution of a handbook on domestic violence to participating physicians, with accompanying decorative bilingual educational office posters and patient information brochures on area domestic violence resources. This collaborative project of the Connecticut Coalition Against Domestic Violence, the University of Connecticut’s Domestic Violence Training Project, and the Hartford County Medical Association was supported by a grant from a local funder, the Hartford Foundation for Public Giving. Thus, communitybased domestic violence services, the medical school, and the local medical society formed a strong base representing expertise in domestic violence, education, and physicians’ interests. The sponsorship board included members from each of these groups as well as physicians in emergency medicine,
Women’s
Health
Issues
Vol.
5, No.
4 Winter
1995
FLITCRAFT:
PROJECT
SAFE
185
internal medicine, pediatrics, and oblgyn. Thus, interdisciplinary interests from medicine, medical education, and community services shared in the evolution and implementation of the project. The project was specifically designed to address barriers to physician education that had been identified in previous research and in domestic violence education endeavors. As outlined above, these barriers include physicians’ limited participation in interdisciplinary educational programs, their perceived difficulties in identifying “at risk” patients, the belief that domestic violence intervention is fruitless, and fear that patients will take offense at questions about domestic violence. Strategies to overcome these barriers thus became the structural framework for Project SAFE.
BARRIER: Limited Physician Participation Education Efforts PROJECT SAFE STRATEGY: Identify Optimum Educational Forum
in Domestic Violence
Grand Rounds as the
Grand rounds are well attended on a regular basis by both private-practice and hospital-based physicians. As a departmental activity, the CME administration is already in place, and no stigma or obligations are attached to participation in a program that addresses this new area for physicians. Grand rounds provide a respected forum to encourage the serious consideration of domestic violence and its associated medical problems. The members of the Project SAFE advisory board were leaders in the Hartford medical community and provided access to and presented at grand rounds in their respective hospitals.
BARRIER: Belief that Domestic Violence Is Only a Problem in Certain Kinds of Practices PROJECT SAFE STRATEGY: All Physicians
Identify
the Target Audience as
Research demonstrates that the presentations associated with domestic violence may vary from practice to practice, but patient surveys consistently indicate significant rates of domestic violence within every practice site and specialty studied. The rate of abuse is surprisingly stable across practice settings, underscoring the similarity-not difference-that physicians face in practice. Addressing all physicians-rather than just emergency physicians or primary care providers---helps to overcome physicians’ fear of isolation and actually reflects the community advocate’s first principle of domestic violence intervention, “You don’t do this work alone.”
BARRIER: Concern About Offending Patients and Belief that Domestic Violence Is Limited to Stereotypic Patients PROJECT SAFE STRATEGY: Call for the Introduction of Routine Assessment for Domestic Violence in Health Maintenance and Acute Care Encounters Much of the early epidemiological research on domestic violence concentrated on identification of clinical presentations that were disproportionately associated with domestic abuse. Much of current literature describes the epidemiology and clinical presentations of abuse in various practice sites. As the 186
FLITCRAFT:
PROJECT
SAFE
Women’s
Health
Issues
Vol.
5, No.
4 Winter
1995
field has moved to a more comprehensive understanding of the dynamics of abuse, it is clear that the health consequences-and presentations-of abuse are myriad. Thus, the notion of “at risk” presentations is one that may prove specific but has already been shown to lack sensitivity. Domestic violence screening is similar to routine assessment for such problems as hypercholesterolemia, smoking, alcohol abuse, breast and cervical cancers, or high-risk sexual behavior. Paradoxically, a shift to routine assessment for domestic violence overcomes the projected stigma and offense associated with trying to identify which patients in a practice “look like battered women.” Imbedding questions about domestic violence routinely into clinical intake evaluations communicates to each patient within a practice-and the community at large-that domestic violence is a health concern and health hazard that may affect anyone.
BARRIER: Fear that Intervention Intervention Is Useless
Is a Pandora’s Box or that
PROJECT SAFE STRATEGY: Identify Competency for All Physicians
a Clear and Limited Basic
Project SAFE sought to articulate a realistic standard of care appropriate to the present level of medical knowledge. Physicians are positioned to identify a broad range of casesbut, if experience with child and elder abuse is analyzed, are reluctant to accept a standard referral protocol, particularly one that appears to supplant the doctor-patient relationship. Although some providers clearly will pursue additional information and training on domestic violence intervention, we identified safety assessment-and triage of crises to recognized experts-as the minimum skill required of every practicing physician. Through Project SAFE more than 750 area physicians participated in grand rounds on domestic violence during an 18-month period. Physician guidelines, posters, and patient education materials were distributed to an additional 500 in response to specific requests during this period. Four of the five hospitals in the area have started interdisciplinary teams to provide crisis intervention and support services to patients and ongoing education to health care providers. New protocols in emergency and ambulatory services contribute to enhanced identification. As research and clinical experience accumulates, as model programs are evaluated and replicated, as medical education advances in this area, medicine’s capacity to respond to victims and perpetrators of domestic violence will improve. Certainly the interdisciplinary teams and enhanced hospitalbased crisis intervention services provide victims of domestic violence and their physicians access to support and critical resources. In the context of continued commitment of such resources, clinical domestic violence intervention might reasonably emerge as a skill maintained by primary care physicians, emergency physicians, and mental health providers. Physicians in other specialty groups may not be able to provide domestic violence intervention but will be able to recognize domestic violence, identify those in need of urgent intervention, and provide safe liaison to expert help. National Ch4E is imperative as it provides for the development of leadership. Changes in medical school curricula will provide young physicians with the knowledge, skills, and attitudes appropriate to domestic violence intervention. However, as Project SAFE illustrates, local CME programs imbedded in the established continuing education structures of hospitals and health maintenance organizations provide an opportunity to build a broad base of shared knowledge
Women’s
Health
Issues
Vol.
5, No.
4 Winter
1995
FLITCRAFI-:
PROJECT
SAFE
187
that can translate into changes in the generally care for victims of family violence in our practices. and support
acceptable
level of
REFERENCES 1. Stark ED, Flitcraft AH. Violence among intimates: an epidemiological review, In: Hasselt VN, Bellack AS, Morrison RL, Hersen M (eds). Handbook of family violence. New York: Plenum Publishing Corp, 1988293-318. 2. Ginn NE, Rucker L, Frayne S, Cygan R, Hubbell AF. Prevalence of domestic violence among patients in three ambulatory care internal medicine clinics. J Gen Intern Med 1991;6:317-22. 3. McFarlane J, Parker B, Koeken K, Bullock L. Assessing for abuse during pregnancy. JAMA 1992;267:3176-8. 4. McLeer SV, Anwar RA, Herman S, Maquiling K. Education is not enough: a systems failure in protecting battered women. Ann Emerg Med 1989;18:651-3. 5. Kurz D, Stark E. Not so benign neglect. In: Yllo K, Bograd M (eds). Feminist perspectives on wife abuse. Newbury Park (CA): Sage Publications, 1988:249-65. 6. Warshaw C. Domestic violence: challenges to medical practice. J Womens Health 1993;2:73-9. 7. Sugg N, Innui T. Primary care physicians’ response to domestic violence. JAMA 1992;267:3157-60. 8. Hendricks-Matthews MK. Survey on violence education: a report of the STFM Violence Education Task Force. Fam Med 1991;23:1947. 9. Chambliss LR, Bay RC, Jones RF. Domestic violence: an educational imperative? Am J Obstet Gynecol 1995;172:1035-8. 10. American Medical Association. State survey results. Newsletter of the National Coalition of Physicians Against Family Violence 1995;1:4.
188
FLITCRAFT:
PROJECT
SAFE
Women’s
Health
Issues
Vol.
5, No.
4 Winter
1995
MD
Associate Professor of Medicine Co-director, Domestic Violence Training Project University of Connecticut Health Center Farmington, Connecticut
F
or more than a decade, domestic violence advocates and health care providers have recognized that education of physicians about domestic violence is a key to the development of a comprehensive health care response to battered women. Every surgeon general since Dr. C. Everett Koop has identified family violence as a major health problem and has called upon researchers and clinicians alike to become a part of the solution. With the growth of the National Center for Injury Prevention and Control at the Centers for Disease Control and an emerging emphasis upon research in family violence, there has been a virtual explosion in knowledge regarding the epidemiology and health consequences of domestic violence. Initial prevalence estimates suggest that at least one adult woman in five will be physically assaulted by her partner. In clinical settings, 22%-35% of injured women presenting to emergency services are abused by partners, 23% of women seen in a family practice clinic and 14% of those in a university internal medicine clinic are in violent relationships, and 17% of obstetrical patients are assaulted during their pregnancy.i” Such figures stand in sharp contrast to rates of domestic violence identified routinely by physicians in these settings. The consistent failure to identify domestic violence in clinical practice has led to an emphasis on protocols and education as tools to help physicians address domestic violence in clinical evaluations. Nevertheless, the task of educating practicing physicians has proved difficult. In one of the first evaluations of a domestic violence protocol, McLeer et al successfully increased the rate of identification of abuse in an emergency department from 5.6% to 30% of female trauma patients. However, upon follow-up evaluation at the same site, rates of identification had dropped back to 7.7%, not significantly different than the baseline rate of identification.4 Kurz and Stark provide a more descriptive evaluation in their study of encounters between battered women and medical staff in a Philadelphia emergency department. They found that in the absence of an onsite advocate, clinicians tended to dismiss abused women as “evasive” and “repeaters” who will “just return home anyway.“5 What are the barriers to changing physicians’ approach to victims of domestic violence? Many barriers to physician education have been identi-
Women’s
Health
Issues
Vol.
5. No.
4 Winter
1995
Q 1995 by The Jacobs
Institute
of
~~~$$$~s SSDI
1049-3867(95)
00052.6
FLITCRAFT:
PROJECT
SAFE
183
fied. McLeer et al conclude that “without institutional policies and procedures for detecting and treating victims of domestic violence, many abused women will pass through unidentified and hence, untreated.“4 Warshaw has characterized barriers within the traditional medical model and in physicians’ ambiguity about abuse of power and control in personal relationships.6 Sugg and Innui identify physicians’ fear of offending patients, sense of powerlessness, and concern over disruptions in schedules as additional barriers that inhibit change in practice standards.7 Connecticut’s Domestic Violence Training Project, founded in 1985 under the state’s Family Violence Prevention and Response Act, is one of the nation’s first programs dedicated to providing domestic violence education for health care providers. Nationally recognized for its interdisciplinary educational programs and technical assistance to hospitals, clinics, and professional organizations, the Domestic Violence Training Project has involved more than 10,000 health care providers in the past decade. During this period, physicians were rare participants in training and educational programs on domestic violence. Our experience with physicians is shared by others in the field, including New York State’s Office for the Prevention of Domestic Violence, founded in 1989. Access to physician audiences has been limited and problematic for many involved in domestic violence educational efforts. In the face of such barriers to educating practicing physicians, more recent initiatives have emphasized the importance of educating medical students about domestic violence. The Domestic Violence Identification and Referral Act, for instance, proposed linking funding of medical schools to implementation of domestic violence curricular reform. The AAMC hosted a consensus conference to identify model undergraduate family violence curricula and strategies for incorporating family violence education into medical school programs. As discussed at this conference, significant efforts to educate medical students and residents are now underway. From The Doctoring Curriculum at the University of California, Los Angeles, to the Primary Care Clerkship at the University of Connecticut, a significant minority of medical students now receive-in core courses or electives-some basic information on domestic violence. Residency programs are undergoing similar change. The Society of Teachers of Family Medicine, in a survey conducted in 1989, found that 41% of programs had at least “some” family violence education and that fully 28% more were planning to expand this content in the curriculum.8 Chambliss, Bay, and Jones report that 28% of ob/gyn residency programs surveyed teach residents to ask all or almost all patients about domestic violence and employ an obstetrician/gynecologist with expertise in domestic violence. Fully 60% of the residency programs were not satisfied with their current curricula, and 70% indicated a need for help in developing or improving their domestic violence curricula.9 All of these authors acknowledge that the figures demonstrate the need for continued curricular development. Nevertheless, the current situation is, in all likelihood, a dramatic improvement from a decade ago, and as Chambliss’ data suggest, we can anticipate that the rate of change will continue. What are the limits of undergraduate and residency training? As the student/young physician advances through education, training, and subspecialty training, the role of the attending physician becomes paramount. The best efforts of the basic sciences faculty are ephemeral unless reinforced and exemplified in the practices of the clinical faculty. As medical education moves from the classroom and hospital to ambulatory care setting, practicing physicians-as attendings and community preceptors-assume an even more important role in the development of young physicians’ practice patterns. Access to attending physicians proves difficult, and changing attendings’ 184
FLITCRAFT:
PROJECT
SAFE
Women’s
Health
Issues
Vol.
5, No.
4 Winter
1995
clinical practice is particularly challenging. But advances in medical education curricula as well as residency training will be blunted unless domestic violence identification and interventions are modeled by attending staff. Continuing medical education thus emerges as an important key in the efforts to change physicians’ response to domestic violence and to incorporate physicians into community-wide domestic violence intervention and prevention efforts. Continuing medical education has been a major project of the professional organizations as they turn attentions to domestic violence. Since 1984, The American College of Obstetricians and Gynecologists (ACOG) has maintained materials, guidelines, and educational seminars on domestic violence for practicing obstetrician/gynecologists. Domestic violence is featured prominently in the American Medical Association (AMA) campaign on family violence, directed specifically to practicing physicians. Indeed, in the wake of the AMA initiative, nearly half of all state medical societies have created task forces, developed protocols, or sponsored recent educational programs on family violence. Many state societies, including those in Massachusetts, Oklahoma, Minnesota, and Ohio, have produced physician handbooks and patient educational materials that provide information and a listing of statewide community services for battered women and their families.” The American Women’s Medical Association’s Advanced Curriculum on Women’s Health and the annual meetings of the American College of Emergency Physicians, American Academy of Family Physicians, and many other medical societies now regularly feature speakers and workshops on domestic violence at annual meetings. In fact, professional organizations have provided the mainstay of clinical activism on this issue. In contrast to the successful activities at the national and state levels, it remains difficult to attract physicians to local interdisciplinary domestic violence conferences. Domestic violence conferences held at hospitals generally include few physicians and physician continuing medical education (CME) tends to be an activity separate from the educational activities of nursing, social work, and administrative staff. However, Dr. Richard Jones of Hartford, Connecticut, was successful in 1993 in translating his own attention to domestic violence as president of ACOG to his local community.
A MODEL
LOCAL
CME
PROGRAM:
PROJECT
SAFE
Project SAFE was implemented in Hartford, Connecticut, in 1993. The target audience for this educational program on domestic violence was the practicing physicians at the five hospitals in Hartford County, Connecticut. The project’s goal was to enhance the health care response to battered women in the Hartford region by encouraging physicians to provide Safety Assessment for Everyone. The specific activities of Project SAFE included grand rounds presentations in various specialties within each of the hospitals and distribution of a handbook on domestic violence to participating physicians, with accompanying decorative bilingual educational office posters and patient information brochures on area domestic violence resources. This collaborative project of the Connecticut Coalition Against Domestic Violence, the University of Connecticut’s Domestic Violence Training Project, and the Hartford County Medical Association was supported by a grant from a local funder, the Hartford Foundation for Public Giving. Thus, communitybased domestic violence services, the medical school, and the local medical society formed a strong base representing expertise in domestic violence, education, and physicians’ interests. The sponsorship board included members from each of these groups as well as physicians in emergency medicine,
Women’s
Health
Issues
Vol.
5, No.
4 Winter
1995
FLITCRAFT:
PROJECT
SAFE
185
internal medicine, pediatrics, and oblgyn. Thus, interdisciplinary interests from medicine, medical education, and community services shared in the evolution and implementation of the project. The project was specifically designed to address barriers to physician education that had been identified in previous research and in domestic violence education endeavors. As outlined above, these barriers include physicians’ limited participation in interdisciplinary educational programs, their perceived difficulties in identifying “at risk” patients, the belief that domestic violence intervention is fruitless, and fear that patients will take offense at questions about domestic violence. Strategies to overcome these barriers thus became the structural framework for Project SAFE.
BARRIER: Limited Physician Participation Education Efforts PROJECT SAFE STRATEGY: Identify Optimum Educational Forum
in Domestic Violence
Grand Rounds as the
Grand rounds are well attended on a regular basis by both private-practice and hospital-based physicians. As a departmental activity, the CME administration is already in place, and no stigma or obligations are attached to participation in a program that addresses this new area for physicians. Grand rounds provide a respected forum to encourage the serious consideration of domestic violence and its associated medical problems. The members of the Project SAFE advisory board were leaders in the Hartford medical community and provided access to and presented at grand rounds in their respective hospitals.
BARRIER: Belief that Domestic Violence Is Only a Problem in Certain Kinds of Practices PROJECT SAFE STRATEGY: All Physicians
Identify
the Target Audience as
Research demonstrates that the presentations associated with domestic violence may vary from practice to practice, but patient surveys consistently indicate significant rates of domestic violence within every practice site and specialty studied. The rate of abuse is surprisingly stable across practice settings, underscoring the similarity-not difference-that physicians face in practice. Addressing all physicians-rather than just emergency physicians or primary care providers---helps to overcome physicians’ fear of isolation and actually reflects the community advocate’s first principle of domestic violence intervention, “You don’t do this work alone.”
BARRIER: Concern About Offending Patients and Belief that Domestic Violence Is Limited to Stereotypic Patients PROJECT SAFE STRATEGY: Call for the Introduction of Routine Assessment for Domestic Violence in Health Maintenance and Acute Care Encounters Much of the early epidemiological research on domestic violence concentrated on identification of clinical presentations that were disproportionately associated with domestic abuse. Much of current literature describes the epidemiology and clinical presentations of abuse in various practice sites. As the 186
FLITCRAFT:
PROJECT
SAFE
Women’s
Health
Issues
Vol.
5, No.
4 Winter
1995
field has moved to a more comprehensive understanding of the dynamics of abuse, it is clear that the health consequences-and presentations-of abuse are myriad. Thus, the notion of “at risk” presentations is one that may prove specific but has already been shown to lack sensitivity. Domestic violence screening is similar to routine assessment for such problems as hypercholesterolemia, smoking, alcohol abuse, breast and cervical cancers, or high-risk sexual behavior. Paradoxically, a shift to routine assessment for domestic violence overcomes the projected stigma and offense associated with trying to identify which patients in a practice “look like battered women.” Imbedding questions about domestic violence routinely into clinical intake evaluations communicates to each patient within a practice-and the community at large-that domestic violence is a health concern and health hazard that may affect anyone.
BARRIER: Fear that Intervention Intervention Is Useless
Is a Pandora’s Box or that
PROJECT SAFE STRATEGY: Identify Competency for All Physicians
a Clear and Limited Basic
Project SAFE sought to articulate a realistic standard of care appropriate to the present level of medical knowledge. Physicians are positioned to identify a broad range of casesbut, if experience with child and elder abuse is analyzed, are reluctant to accept a standard referral protocol, particularly one that appears to supplant the doctor-patient relationship. Although some providers clearly will pursue additional information and training on domestic violence intervention, we identified safety assessment-and triage of crises to recognized experts-as the minimum skill required of every practicing physician. Through Project SAFE more than 750 area physicians participated in grand rounds on domestic violence during an 18-month period. Physician guidelines, posters, and patient education materials were distributed to an additional 500 in response to specific requests during this period. Four of the five hospitals in the area have started interdisciplinary teams to provide crisis intervention and support services to patients and ongoing education to health care providers. New protocols in emergency and ambulatory services contribute to enhanced identification. As research and clinical experience accumulates, as model programs are evaluated and replicated, as medical education advances in this area, medicine’s capacity to respond to victims and perpetrators of domestic violence will improve. Certainly the interdisciplinary teams and enhanced hospitalbased crisis intervention services provide victims of domestic violence and their physicians access to support and critical resources. In the context of continued commitment of such resources, clinical domestic violence intervention might reasonably emerge as a skill maintained by primary care physicians, emergency physicians, and mental health providers. Physicians in other specialty groups may not be able to provide domestic violence intervention but will be able to recognize domestic violence, identify those in need of urgent intervention, and provide safe liaison to expert help. National Ch4E is imperative as it provides for the development of leadership. Changes in medical school curricula will provide young physicians with the knowledge, skills, and attitudes appropriate to domestic violence intervention. However, as Project SAFE illustrates, local CME programs imbedded in the established continuing education structures of hospitals and health maintenance organizations provide an opportunity to build a broad base of shared knowledge
Women’s
Health
Issues
Vol.
5, No.
4 Winter
1995
FLITCRAFI-:
PROJECT
SAFE
187
that can translate into changes in the generally care for victims of family violence in our practices. and support
acceptable
level of
REFERENCES 1. Stark ED, Flitcraft AH. Violence among intimates: an epidemiological review, In: Hasselt VN, Bellack AS, Morrison RL, Hersen M (eds). Handbook of family violence. New York: Plenum Publishing Corp, 1988293-318. 2. Ginn NE, Rucker L, Frayne S, Cygan R, Hubbell AF. Prevalence of domestic violence among patients in three ambulatory care internal medicine clinics. J Gen Intern Med 1991;6:317-22. 3. McFarlane J, Parker B, Koeken K, Bullock L. Assessing for abuse during pregnancy. JAMA 1992;267:3176-8. 4. McLeer SV, Anwar RA, Herman S, Maquiling K. Education is not enough: a systems failure in protecting battered women. Ann Emerg Med 1989;18:651-3. 5. Kurz D, Stark E. Not so benign neglect. In: Yllo K, Bograd M (eds). Feminist perspectives on wife abuse. Newbury Park (CA): Sage Publications, 1988:249-65. 6. Warshaw C. Domestic violence: challenges to medical practice. J Womens Health 1993;2:73-9. 7. Sugg N, Innui T. Primary care physicians’ response to domestic violence. JAMA 1992;267:3157-60. 8. Hendricks-Matthews MK. Survey on violence education: a report of the STFM Violence Education Task Force. Fam Med 1991;23:1947. 9. Chambliss LR, Bay RC, Jones RF. Domestic violence: an educational imperative? Am J Obstet Gynecol 1995;172:1035-8. 10. American Medical Association. State survey results. Newsletter of the National Coalition of Physicians Against Family Violence 1995;1:4.
188
FLITCRAFT:
PROJECT
SAFE
Women’s
Health
Issues
Vol.
5, No.
4 Winter
1995