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Monday Jan 21, 2013

Asking Tough Questions About Abuse Can Save Lives

It was more than 20 years ago, but some patients you never forget.

I was not the primary care physician for this new baby girl, but I was on call when her mother brought her in for a well visit. I had treated the mother, her husband and their other children before during sick visits. They seemed like an average family.

During our last visit, the mother and I talked about typical new baby topics -- car seats, breastfeeding and immunizations. What I didn't know at the time was that this young woman was desperately looking for a way out of an abusive relationship.

I was a new physician, just three years out of residency. Although I asked important questions about the child's health and safety, I didn't know to ask the mother about her own safety. Back then, we didn't know that homicide -- not bleeding, blood clots or infections -- is one of the leading causes of death in women in the first year after childbirth.

Now we know.

That woman wanted to find a better, safer place for herself and her children, but a short time later she was dead. The baby's father killed the mother, their older children and two other family members before a failed attempt to take his own life. The infant survived.

I remember my practice partner -- who was their primary care physician -- crying while dictating notes from their files. She stopped the recorder and said, "This family could have made a difference."

For me, they did.

I wanted to learn more. What could I have done differently? What was the dynamic in that family that led to this horrible act? Could it have been prevented?

The U.S. Preventive Services Task Force has published new recommendations that call on physicians to screen all women of childbearing age for intimate partner violence and to refer them to intervention services, if needed.

It's good advice. We can save lives with the right information. I have seen an extraordinary number of positive outcomes when a physician understands the dynamic of what his or her patient is living with.

One excellent screening tool is RADAR, which prompts physicians to follow these steps in a private setting:

  • Routinely screen female patients;
  • Ask direct questions; 
  •  Document your findings;
  • Assess patient safety; and
  • Respond, review options and refer.

The recommendation to screen all women of childbearing age is a good one. I have heard disclosures about abuse from politicians, judges and colleagues. It's worth noting that men and children also are at risk. Sadly, abuse happens all the time in every community, and you never know who might need help.

A variety of conditions could raise a red flag. If a patient is experiencing things such as anxiety, chronic pain, depression or eating disorders, go upstream. What is causing those problems? Don't be afraid to ask difficult questions when you are alone with the patient, such as

  • Are you safe?
  • What happens when you argue?
  • Are you afraid to go home?

This is something family physicians can, and should, do. And just a few minutes of our time can make an unbelievable impact in the long term.

So what do you do when a patient is willing to confide in you? Telling him or her to "just leave" an abusive relationship is not the answer. Know the resources and shelters in your community. Often, I've taken a patient to a private place in my practice, dialed a shelter for them, started that important first call and then left the room so that the patient could talk in private.

We can help our patients with a better outcome and better quality of life. But we have to be willing to start the conversation.

Wanda Filer, M.D., M.B.A., is a member of the AAFP Board of Directors.

Comments:

Excellent advice. Would you share your opinion on IPV screening of male victims? All the focus seems to be on female victims, while the CDC's 2010 report for rape, physical violence, and/or stalking reveals a prevalence of 42 million women and 32 million men, with an incidence of 7 million women and 5.7 million men. Thank you.

Posted by Hermann J. Stubbe on January 24, 2013 at 12:03 PM CST #

Personally, I screen any patient, male or female when I have any concern and the patient is being seen alone (the companion may be the abuser). For males I use a more directed screening approach, women more universal. USPSTF uses evidence to determine recs and the data on screening men is somewhat lacking. The advantage as a Family doc, however, is that we care for every patient and use that to guide our actions. I have uncovered abuse in men, although less often physical, more mental or psychological. Women are more likely to sustain serious or fatal physical injuries than men. It can be much more difficult for a man to disclose or even acknowledge to himself. Making any patient feel respected and believed goes a long way to facilitating disclosure and opening next steps to increase safety.

Posted by Wanda Filer on January 24, 2013 at 07:11 PM CST #

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The opinions and views expressed here are those of the authors and do not necessarily represent or reflect the opinions and views of the American Academy of Family Physicians. This blog is not intended to provide medical, financial, or legal advice. All comments are moderated and will be removed if they violate our Terms of Use.