Integrating Routine Inquiry about Domestic Violence into Daily Practice

Domestic violence terrorizes the lives and damages the health of millions of women each year (1, 2). Studies indicate that 21% to 54% of women seen in emergency departments or primary care clinics have reported physical or emotional abuse by a partner in adulthood and at least one in three have experienced some form of abuse during their lives (3-5). Research over the past two decades has continued to document the profound effects of domestic violence on women's health (6-10). For many victims, the health care setting is the only place they will seek help, and health care providers play a critical role in creating a safe atmosphere for patients to discuss the abuse that they have experienced. Most Americans feel that, if asked, they could talk to a physician about domestic violence, and more than half feel that physicians could help in such situations (11). However, battered women identify medical providers as being among the least effective professional sources of help. Rodriguez and colleagues (12) asked formerly battered women about their experiences with the health care system. These women reported that disclosure was difficult, in part because of the clinician's failure to ask about battering during the medical interview. Over three quarters of the cohort favored direct inquiry about domestic violence as a routine component of the clinical encounter. New guidelines have evolved to address domestic violence within the health care setting. The Joint Commission for the Accreditation of Health Care Organizations, for example, now requires hospitals and clinics to institute protocols and training to help providers identify victims of abuse, assess their needs, provide interventions, and make referrals to community-based advocacy services. Nonetheless, many clinicians still have difficulty integrating routine inquiry about domestic violence into their daily practice (13). In this issue, Gerbert and colleagues (14) sought to learn about screening practices and reactions to patient disclosure by clinicians experienced in caring for abused patients. Their findings underscore existing recommendations for addressing domestic violence within the health care setting (15-20), including establishing trust and emotional safety before asking about abuse, framing questions in ways that reassure patients that they are not alone and that help is available, and reconceptualizing the clinician's notion of success. Yet even the experienced physicians in this study acknowledged that they do not always ask about abuse. Some forget to ask, whereas others are reluctant to inquire unless signs or symptoms of abuse are present. What keeps even committed physicians from routinely asking about domestic abuse? Universal screening guidelines evolved through attempts to incorporate public health and advocacy models into traditional clinical practice. Because domestic violence is so prevalent and its presentations are so varied, inquiring only when abuse is suspected is no longer considered adequate. Many victims of abuse seek help for common medical problems, such as asthma, diabetes, and hypertensionconditions that may not be considered red flags for abuse. Unless clinicians ask routinely, many cases of domestic violence will be missed. Given the constraints under which most physicians practice, it is essential that questions about abuse be fully integrated into the medical history rather than viewed as optional components to be added when there is time. Screening for domestic violence has implications beyond that of early-stage detection of prevalent and treatable diseases, the goal of most screening initiatives in medicine. Universal screening for domestic violence is, in fact, an intervention in itself, because it lets patients know that domestic violence is not acceptable and that help is available regardless of whether or not they choose to disclose. Nondisclosure does not necessarily mean that the patient has not noted the physicians' concern or the information provided. Many women disclose abuse only after numerous physician inquiries. Asking about domestic violence signals patients that should domestic violence ever become a problem, the patient can seek help from a physician. Participants in Gerbert and colleagues' California-based study expressed frustration over low disclosure rates of abuse, even after direct inquiry (14). It is possible that disclosure rates elsewhere are higher than in California, a state with an existing, albeit hotly debated, mandatory reporting statute. Physician and patient objections to mandatory reporting need to be considered in states that are contemplating similar legislation. As Gerbert and colleagues (14) describe, frustrations about nondisclosure also stem from physicians' notions of success. Perhaps the emphasis on screening has generated some confusion about what it is we are asking physicians to doroutinely ask all women (and men at increased risk) about abuse. The term routine inquiry may better approximate the type of universal screening necessary for addressing domestic violence. The point is not identification of disease but provision of information, support, and a safe atmosphere for discussing abuse if and when a patient chooses to do so. Clearly, asking about domestic violence demands more of physicians than other types of screening, and, as Gerbert and colleagues (14) comment, domestic violence protocols alone are not sufficient to help physicians address this issue. Institutions must encourage clinicians' efforts to address these complex issues and provide the emotionally supportive atmosphere needed for dealing with painful, frightening situations. Educators need to provide training experiences that foster the development of attitudes and skills to navigate personal, professional, and societal barriers, and insurers must reward the integration of these competencies into practice (19). Without such changes, we will continue to produce practice environments in which people in great jeopardy will not receive the help they need. Because domestic violence is a complex social problem rather than a strictly biomedical one, addressing it adequately obliges physicians to step beyond traditional medical paradigms. In so doing, they also need to confront the personal beliefs and feelings that shape their responses to patients, to consider larger social issues in addition to treating symptoms, and to work in partnership with community groups committed to ending domestic violence (19). Clinical interventions are more likely to be effective if they are joined with pragmatic policies regarding screening, a broad, multidisciplinary commitment to a resilient community-based infrastructure than can protect battered women and their children from harm, and a long-term strategy for ensuring economic and emotional empowerment for survivors. Most important is to remember whom these interventions are for and what outcomes we seek. In a profession where competence is tied to a sense of mastery and control and in which one is rewarded for clinical success, we may forget that patients may define outcomes very differently than we do. More work is needed to understand what abused patients want from physicians, what they do and do not find helpful, and how they themselves would define success.