Trusted Relationship Allows Patients to Confide Horrors of Abuse
"Doc, I trust you ..."
Lately, I feel as if I have been hearing this phrase on a daily basis. I have to admit, it makes me anxious because of its power and weight.
It may be said jokingly at the end of an unsolicited recommendation, and it has been expressed seriously after a long conversation. Regardless, I never take it lightly. It is a strong reminder of my responsibility and the need for me to fully embrace my calling to heal.
Recently, "Doc, I trust you," has been followed by stories of abuse. The spectrum is vast, including physical, emotional, sexual, mental and financial abuse and neglect. Regardless of type, the stories are painful. And words, I am sure, only minimally describe a person's feelings or experience.
My patients' stories often begin with a reference to trust for a variety of reasons: to ask for a listening ear to unload a hurtful past, to request assistance in locating and accessing resources, or to get medical evaluation and treatment in the aftermath. I have treated bruises, scratches, neck strain, anxiety, posttraumatic stress disorder, emotional agony, etc.
There are also the wounds that are more subtle and may go unnoticed without a request for help.
Most commonly, abuse is inflicted by someone the victim knows well. It can put family physicians in a strange position because we may also know and provide care for the abuser. I must admit such cases have been some of the most difficult for me.
The statistics of abuse in the United States are staggering:
- One in three women and one in four men have been victims of physical violence or stalking by an intimate partner in their lifetime.
- One in five women and one in 71 men have been raped in their lifetime.
- Among victims of rape, 40.8 percent of females and 52.4 percent of males were raped by an acquaintance.
- After motor vehicle accidents, the second-leading cause of death among pregnant women is homicide.
- More than 700,000 children are abused annually.
As physicians, we are mandatory reporters of "certain injuries or cases of abuse or neglect to law enforcement, social services, and/or a regulatory agency." In almost all states and territories, physicians are specifically mandated by law to report suspected or observed child maltreatment, as well as elder abuse, neglect and exploitation. The rules of reporting intimate partner violence are much more variable by state.
The AAFP and the U.S. Preventive Services Taskforce recommend that clinicians screen women of childbearing age for intimate partner violence. Those who screen positive should be provided or referred to intervention services.
Detecting abuse, however, can be difficult. Although screening tools are available to help us broach a topic that may otherwise go unaddressed, it has been my experience that it is the continuity and level of trust that a patient has with his or her physician that determines whether the truth will be revealed. It has taken years for some patients to confide in me, while others open up during a second or third visit. I have left the door open for each of my patients to share things about themselves that may help me to improve their quality of life.
Here are a few simple steps we can take.
- Make time to listen. One of the times I heard, "Doc, I trust you ... can I tell you something?" my hand was literally on the doorknob. It took a reminder of the gravity of my job, and the tone of importance conveyed by my patient, for me to remove my hand and truly enter into what this encounter was meant to be -- a healing space.
- Make an effort to screen for intimate partner violence. As they say, practice makes perfect. Although you will get many "nos," the "yes" that you inevitably hear could one day actually save a life.
- Be aware of the resources available in your clinic and your community for patients who are seeking help.
- Finally, don't hold on to all the heaviness. Some of the stories we hear from patients can weigh us down with the ills of mankind. Consider counseling, discussing the issue with a mentor/colleague, meditation, writing, or something else you feel comfortable with. Finding a way to release this tension is important to our ability to continue to take care of our patients and to care for ourselves.
Venis Wilder, M.D., is a board-certified family physician who practices at a federally qualified health center in Harlem, N.Y. She also considers herself a community health practitioner working at the intersection of primary care and public health.
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