The right questions can stop abuse

Karin V. Rhodes surveyed women like Vera Womock (right), pictured with her grandson, Hajii, as part of a study to find out how doctors can help
prevent domestic violence.

Photo credit: Candace diCarlo

According to the National Violence Against Women Prevention Research Center, between 23 and 66 percent of American women will be physically assaulted by a spouse or live-in companion during their lifetimes. But while many of these women seek care for their injuries in hospital emergency rooms, their abuse often goes unreported.

Karin V. Rhodes, director of Penn’s Health Care Policy Research in the Department of Emergency Medicine, says she might understand why. In a new study, Rhodes finds that poor provider-patient communication can be a cause of this underreporting of domestic abuse.

Titled “You’re Not a Victim of Domestic Violence, Are You?” the study examined 871 audiotaped provider-patient conversations, including 293 in which the provider screened for domestic violence. The recordings were made as part of a larger study evaluating the utility of a computerized screening intervention to identify domestic violence.

The conversations were taped at two socially and economically disparate emergency departments in the Chicago area. One was an urban academic medical center serving a predominately African-American, publicly insured population; the other a suburban community hospital serving a predominately white, privately insured population.

Rhodes, an emergency physician, says she undertook the study, funded by the Agency for Healthcare Research and Policy, because she has been aware for some time that many of her patients suffer from domestic violence. “I know it impacts their health in very negative ways so I wanted to get doctors and nurses screening for this,” she says. “I knew that patients would tell you [about the abuse] and patients actually liked being asked, and thought it was important information for the doctor to know. They are very aware that it impacts their health.”

Domestic violence discussions studied were almost always initiated by providers asking social history questions as part of a checklist of risk factors. Providers would ask, “Do you smoke? Do you drink alcohol often or use any street drugs? Do you have any problems with domestic violence?” If a patient answered “No,” the provider would often simply move on.

Occasionally, providers would frame their domestic violence inquests in a negative way, such as “He’s never hit you?” In one instance, a provider made a joking reference to domestic abuse and asked about it with the patient’s male partner present. In another, a provider failed to follow up on a domestic violence claim because the abuser was not an intimate partner.

Additionally, the study found that doctors were more likely to discuss domestic abuse with inner city patients than with suburban ones. Rhodes says there is a “screening bias” among suburban doctors. “I think that [for] doctors, it’s easier for them to think that domestic violence happens to someone else,” she says. “It’s sort of like, if you think it only happens to poor people …” then providers will fail to screen the more affluent.

Both lack of training and lack of time can result in poor doctor-patient communication, Rhodes says.

“The emergency department is busy but when people responded, it did not take them that long,” she says.

By showing empathy, asking follow-up questions, and asking open-ended questions, providers can be much more effective in getting patients to disclose domestic abuse, the study concluded.

Instead of asking perfunctory questions, such as “You’re not a victim of domestic violence, are you?” Rhodes and her colleagues recommend asking questions like:
• “Are you in a relationship where you have been hit or threatened?”
• “Has anyone ever treated you badly or made you do things you don’t want to do?”
• “Is there anyone you are afraid of?”
• “Do you and your partner fight a lot—does it ever get physical?”

Even asking about general health issues can be helpful. One provider was able to get a patient to disclose information about her abusive father merely by asking about her stress level.

Rhodes says it is important to give the patient a chance to report domestic violence and utilize domestic abuse services. She says she hopes the study is a wake-up call.