Core competence in screening, recognizing, and treating the short- and long-term manifestations of violence in intimate relationships is increasingly expected as the standard of care for internists and other generalist and specialist physicians. Yet, most practicing physicians have received no education or training in this area during medical school, residency training, or continuing education [1-4].

The objectives of this paper are the following: 1) to help physicians better recognize and understand the spectrum of clinical manifestations of intimate partner violence; 2) to introduce and reinforce the concept of routine periodic inquiry regarding current, past, or potential victimization as a component of standard patient care in generalist and subspecialist practice; 3) to discuss the range of difficulties that battered women face in leaving abusive relationships and in accessing and interacting with the health care system; 4) to discuss the logistic and attitudinal barriers that physicians face when confronting issues of violence and abuse in their practice settings; 5) to summarize for practicing physicians the skills that can be used in the care of patients who may be at risk for or suffering the effects of intimate partner violence; and 6) to enable physicians to gain a new understanding of violence in the context of the life cycle of the patient as a member of a family and community and of the medical, social, and cultural contexts of violence as learned behavior in our society.

Background and Definitions

Relationship violence can be defined as intentional violent or controlling behavior in the context of an intimate relationship [5]. Although most victims of domestic violence are women in heterosexual relationships [6], the incidence and prevalence of domestic violence appear to be similar in male and female homosexual relationships [7, 8]. This finding underscores the predominant constructs of power and control in this syndrome as opposed to gender. Thus, violence throughout the human life cycle, expressed as child abuse and neglect, dating violence, domestic violence, elder abuse, and abuse of the disabled can be viewed as learned behavior manifested to assert power and maintain control.

Domestic violence encompasses not only physical injury but also threats, sexual abuse, emotional and psychological torment, economic control, and progressive social isolation [9]. In fact, physical violence usually occurs in the setting of a prodrome of nonassaultive behaviors, which can occur in any combination over a varying time course.

Risk Factors and Clinical Characteristics

It is widely acknowledged that domestic violence is prevalent in all racial, educational, geographic, and socioeconomic segments of society. Various clinical and demographic characteristics of women who are currently being physically abused have been elucidated in the study by McCauley and colleagues in this issue of Annals [10]. In addition to acute physical trauma, domestic violence is associated with many physical and psychological sequelae, including multiple somatic symptoms [11]; chronic abdominal pain [12]; chronic headaches [13]; pelvic pain [14, 15]; and anxiety, depression, post-traumatic stress syndromes, and other psychiatric disorders [16]. Alcohol and drug addiction, musculoskeletal symptoms, and eating disorders are other health-related sequelae of short- and long-term abuse [17]. Physical violence seems to be particularly common during pregnancy, with prevalence estimates ranging from 16% to 37% [18-20].

Obstacles to Leaving an Abusive Relationship

Many battered women endure a pattern of progressively escalating violence over months to years but remain in the abusive relationship. Understanding why battered women do not "just leave" is key to the delivery of compassionate and effective care.

See related articles on pp 737-46, 782-94, 800-2, and 804-5.

Fear

Battered women harbor legitimate fear for the physical safety of themselves and dependent family members. Indeed, such women are well aware that leaving does not necessarily mean safety. It is not uncommon for a battered woman to report threats of harm or even death against herself, her children, or other family members should she attempt to leave. In fact, because the most dangerous time for a battered woman is when she does attempt to leave, safety planning is a key element in the care of such patients.

Financial Constraints

Battered women often lack access to the economic resources necessary to gain and maintain independence. In addition to the increased prevalence of violence seen in poorer women [10], battered women are often denied access to liquid assets available to their partners such as bank accounts, credit cards, and cash. It is thus nearly impossible for such women to secure independent credit, establish a new apartment or other living arrangement, or simply afford the bus or taxi fare that is often necessary to flee the batterer.

Social Isolation

Battered women tend to become progressively isolated from friends, family, and community as they try to conform to rigid rules of behavior within the household. The batterer often restricts or denies the victim access to friends, family, the telephone, and even commonly available media such as radio and television. As a result, the battered woman becomes progressively isolated and dependent on the batterer as her sole source of social and emotional support.

Feelings of Failure

Battered women frequently express emotions such as shame, humiliation, low self-esteem, and feelings that she somehow caused her partner to be abusive and thus deserves to be abused. Such profound feelings of failure are too commonly reinforced by both explicit and implicit messages, by individuals and groups, of the responsibility of the battered woman not only to stay in the relationship but also to try to make it better. Thus, the woman not only feels ashamed of her situation but also of her inability to change it. Recurring feelings of shame, worthlessness, and helplessness often accompany reactive chronic depressive symptoms.

Promises of Change

Episodes of violence are typically followed by a "honeymoon" period of variable length. During the honeymoon phase, the batterer often behaves in a manner that is construed as loving, tender, apologetic, and remorseful and that is accompanied by promises that he will change his behavior. These seemingly tranquil periods are typically followed by an increase in tension, culminating in a subsequent violent episode [21]. Despite the predictable nature of this "cycle of violence," loving and tender behavior between abusive episodes can serve as a powerful force that often influences the battered woman to remain with her abuser, in the hope that the violence will ultimately abate.

Unresponsive Support Network

Domestic violence is endemic in society and until recent years was statutorily legal, affording women little protection under the law. Although abuse prevention laws have been enacted in all 50 states, intervention programs and legal protections for battered women and their children remain less than adequate. More importantly, community-based primary prevention and education programs, the most essential cornerstones of a comprehensive, effective, and long-term solution to violence in our society, are being de-emphasized, down-sized, or even dismantled in the current economic and political environment. Further-more, through frequent and graphic news and entertainment media offerings, U.S. society has been desensitized to the horrific effects of abuse. A culture in which violence is normalized, bought, sold, and even admired cannot effectively respond to the multifaceted problem of violence because it is constrained in its ability to support effective community, state-wide, and national responses.

Obstacles Patients Face in Approaching Physicians about Violence and Abuse

Although the general public is now beginning to expect that physicians know about domestic violence, most patients do not believe their physician knows about the issue, would know what to do, or even cares about domestic violence. Many patients are reluctant to disclose, especially initially, because of shame, fear of loss of confidentiality, or fear of reprisals from the batterer, especially if the abuser uses the same physician or health care facility. Some patients also feel they are not allowed to bring up an issue, particularly one that is not "strictly medical," unless directly asked. As a corollary, subtle and usually unintentional victim-blaming statements, minimization, and denial on the part of some health care providers could reinforce the patient's sense of shame, humiliation, and responsibility about the violence and can prevent some patients from seeking help in the health care setting. Finally, some patients fear a denial or revocation of health, disability, or life insurance benefits if their abuse is discovered.

Although most battered patients do not volunteer a history of violence to the physician unless directly asked, the rate of disclosure increases substantially when routine inquiry is instituted in an empathic, confidential, and non-judgmental manner [22-24]. However, physicians typically fail to ask about violence and victimization during the medical encounter [25-27]. Thus, it is imperative that routine confidential inquiry become part of the medical standard of care in primary care and emergency practice settings.

Clinical Evaluation Strategies

The acronym "RADAR" Table 1 serves as a useful clinical practice tool for the physician. Adhering to such an algorithm can promote a stream-lined, effective response for both emergent and nonacute situations. The appropriate role of the physician is as a member of an advocacy team that includes essential community-based "experts," health providers, and legal resources. This team should be individually assembled for each patient and should operate in a coordinated and supportive manner to confidentially assist the patient in acquiring sufficient knowledge and resources so that she can make informed choices about her own (and her dependent children's) health and safety. It should be emphasized, particularly in cases of domestic or family violence, that the appropriate role of the physician is not necessarily to know all and do all but to screen, document, validate, and refer.

The Patient Interview

Routinizing Inquiry

All patients, both female and male, should be asked about a history of current or past abuse during the routine patient interview and periodically thereafter. Although these questions are awkward to ask at first, the physician rapidly adapts the line of inquiry to his or her own personality and interview style. It is often advisable to precede questioning about abuse with a statement of awareness of the prevalence and seriousness of domestic violence and that the physician is now asking all patients about this important issue. I then ask, "At any time [or in the case of a periodic or return visit, ‘in the last year,’ or ‘since I last saw you’ ... ] has your husband/boyfriend/partner/lover hit, kicked, threatened, or otherwise hurt or frightened you?" It is important to be sensitive to the possibility of intimate violence perpetrated by women in lesbian relationships and by men in homosexual relationships, while maintaining an awareness that some homosexual persons choose not to disclose their sexual orientation to their physicians.

Following through on Disclosure

If the patient discloses a history of abuse, the physician should continue the inquiry, establishing a more detailed chronology of the violence. Questioning about the first episode, the most recent episode, and the most serious episode often helps the physician quickly assess severity. The patient should be asked about previous visits to emergency facilities for treatment, threats, or injury with a weapon (blunt object, knife, or firearm). The deleterious effects on children who witness physical violence between their parents or caregivers is well documented [1, 28]. Therefore, if children are living with the patient, it is important to ask if the children have seen or heard threats or assaults or have been threatened or assaulted themselves by the abuser. The physician's duty as a mandated reporter should be remembered when issues of children at risk arise in the context of patient care. In addition, the patient should be given time to tell her story using an open-ended query format, with the physician maintaining a compassionate, nonjudgmental stance.

Assuring Confidentiality

Confidentiality in the patient care setting must be assured and honored [23], not only because all physician-patient communication should be considered confidential [29], but also because many battered women live in fear of serious injury or death if anyone "finds out." The patient should be interviewed in a private setting, without the partner, children, neighborhood interpreters, or anyone else known to the patient in attendance. The patient will make the correct choice not to disclose, even in the presence of ongoing abuse, if confidentiality cannot be assured.

Maintaining Advocacy

The patient should be validated and supported during the initial interview and throughout the encounter. Statements such as "you did not deserve to be hit/abused/beaten/threatened," "violence is never an acceptable way to resolve conflict," "I am concerned for your safety and well-being," and simply, "I care about you as my patient," can help establish trust and confidence in the physician-patient relationship and begin the initial process of empowerment and healing for the patient.

Refraining from Blaming the Patient

Although it is appropriate to ask what happened and how the patient can get to safety if and when another violent episode occurs (see below), the physician should never ask questions or make statements that reinforce the patient's sense of shame, humiliation, blame, powerlessness, and failure. The following are examples of such victim-blaming questions and statements: "What do you think you might have done to bring on the violence?"; "What could you have done to prevent the violence?"; "If it were me, I wouldn't stay with him"; "Why don't you just leave if he is battering you?"; "What keeps you with a person like that?"; and "I just can't help you any more if you aren't going to do something about your situation."

Putting Aside the "Quick Fix"

Although the physician may wish his or her patient could get away from the batterer, it is often not feasible or even possible for the victim to leave. If a battered woman feels incapable of leaving the abusive setting but is told by her physician that she must do so, she will probably feel even more like a failure and risk being viewed as a "noncompliant" patient. In fact, most battered women who leave have unsuccessfully attempted to leave in the past.

Leaving the Door Open

Even in situations of ongoing domestic violence, some patients may not disclose such information, even if asked directly, because of fear of reprisals, shame, or fear of losing insurance benefits. The patient may also mistrust the health care system in general. It is therefore important, especially when suspicious findings are noted, to leave the door open by saying, "I understand this is an issue you may not want to talk about at this time, but in my experience as a physician, when I see injuries or conditions such as yours, very often it is because someone is being intentionally hurt, usually by a partner. If this is the case, I stand ready to listen and to help you when you are ready, and my office staff/nurse/social worker could also help you with this in a manner that is strictly confidential."

The Physical Examination

Suspicious Findings

A woman who presents with any injury, particularly if she has previously used emergency department facilities for any reason, should be considered a victim of domestic violence until proven otherwise. Such patients should undergo a careful physical examination, and the examiner should suspect intentional violence, particularly with respect to trauma in central areas of the body, such as the face, abdomen, breasts, and genitals. The physician should also especially consider bilateral or multiple injuries, injuries that are in different stages of healing, and a delay between the time of injury and arrival to the health care setting as arising from intimate partner violence. Although injuries to the central areas of the body predominate, contusions of the ulnar aspects of the forearms are not uncommon; such injuries usually result from blows sustained by the woman as she attempts to protect her face from injury during an assault. In addition, because sexual assault is not uncommon in intimate violence situations, the physician should ask about and assess the patient for such assault. Battered women often try to hide their injuries with make-up or long clothes.

Inconsistencies between the Patient's History and the Physical Examination

In situations of domestic violence trauma, the patient's explanation of the injury is often inconsistent with the type and pattern of injury. These patients usually do not feel comfortable disclosing the cause of the violence unless directly asked in a nonjudgmental manner that supports her safety and confidentiality.

Psychological and Somatic Manifestations

Victims of domestic violence often present not with physical injury but rather with chronic symptoms that are not accompanied by discernible physical findings; these symptoms include headache, shortness of breath, atypical chest pain, abdominal pain, pelvic pain, musculoskeletal pain, dizziness, irritability, insomnia, anxiety, panic symptoms, post-traumatic stress disorder, depression, and alcohol or other substance abuse.

The Pregnant Patient

Because physical violence often begins or escalates during pregnancy, particular consideration should be given to screening pregnant women for current abuse. During each prenatal visit, the breasts and abdominal area should be visually inspected for contusions, and the patient should be asked, "Have you been hit, hurt, or threatened since I last saw you in the office?"

Documentation in the Medical Record

Documentation of significant history and physical findings is an important aspect of the care of battered patients. Whenever possible, historical accounts should be recorded as written narratives of the patient's words. Physical findings can be documented using physician narrative, labeled free-hand sketches or cartoon predrawn figures, or instant photographs.

Documentation of domestic violence in the medical record can be a source of invaluable information to a patient should she ever seek legal redress from the batterer, if a prosecutor decides to proceed in a criminal complaint with or without her testimony, or in a potential custody dispute.

Assessment of Danger

Once a careful history and physical examination have been conducted, the physician should then assess the patient's short- and long-term risk for injury or death. The most important determinants of risk are the woman's assessment of her immediate and future danger, the presence of "crescendo violence" (that is, violence that is increasing in frequency or severity), threats of homicide or suicide by the partner, and the presence or availability of a firearm or other lethal weapon. To assess the patient's own sense of danger, the physician should ask, "What is your sense of your safety right now? Are you afraid to go home today?" Statements made by the batterer to the patient such as "If you leave, I will find you and kill you"; "If you leave, I will kill myself"; or "If you leave, I will get the children and you will never see them again" should be taken very seriously and acted on with urgency.

Intervention Strategies

The physician has four main areas of responsibility in intervening in domestic violence issues: 1) communicating concern and validating the patient, 2) providing medical treatment, 3) reviewing options and facilitating appropriate referral and follow-up, and 4) assuring the generation of an individualized safety plan. Awareness and acknowledgment that the patient has choices that will be respected and resources that can be accessed can be a transforming and empowering experience to a patient who has felt continually victimized and powerless because of long-standing abuse.

Communicating Concern

Reassigning Accountability and Responsibility

It is crucial to reframe the abuser's violent behavior as unacceptable. Empathic statements of concern and validation can serve as powerful therapeutic tools and are easily used in the clinical encounter.

Acknowledging the Patient's Dilemma

If the patient cannot or is unwilling to disclose suspected battering, or if she has disclosed such information but has chosen not to leave the battering situation, the physician should let her know that he or she will nonetheless remain available to offer assistance and support. Phrases such as "You did not deserve to be hit or hurt, no matter what happened"; "I am concerned for your safety, and for the safety of your children"; "In my experience, the violence does not go away, it generally gets worse over time"; and most importantly, "I am here to advocate for you and help you get to safety whenever you are ready to do so" can be intensely powerful therapeutic tools in the office setting.

Focusing on the Patient's Strengths

A focus on the woman's strengths in adverse circumstances, such as managing the household, raising children, and taking prescribed medications regularly, can be a positive therapeutic strategy in view of the pervasive sense of failure and shame with which most battered women live.

Providing Medical Treatment

Although the physician plays an important role in the multidisciplinary hospital, office, and community team caring for battered women, he or she is the only one who can direct and provide immediate and follow-up medical care. Patients who present to emergency settings should be referred for subsequent longitudinal care to a primary care physician, preferably one who has training, expertise, and sensitivity in caring for victims of intimate partner violence.

Reviewing Options

Facilitating Referral

The physician should review the options available to the patient and make appropriate referrals. Just as in the care of patients with cancer, the physician should provide the patient with information on available options and resources, as well as support in making informed decisions regarding her care. The battered woman may choose to return home to the abuser because she may not feel ready or able to leave at the time of the encounter with the physician. An emergency shelter (assuming available space) is another option if the patient does not feel she can safely return home.

So that optimal care is rendered and the burden on the physician is minimized, each patient who is a victim of abuse should be referred to a telephone hotline, a battered women's advocate, or a similar resource whenever possible. Battered women's services, usually originating from emergency shelters, are free, confidential, expert, and empowering and can provide survivors of domestic violence with vital follow-up care.

Cautionary Notes about Couples Counseling

Couples counseling is contraindicated in cases of active domestic violence [30]. Although practiced by some family therapists in cases in which the level of violence is considered to be low [31], couples counseling should be avoided in the primary care setting.

Legal Referral

Many battered women can benefit from access to basic legal information and assistance through referral to an attorney, court advocate, or legal services center. The physician can serve a key role in providing telephone numbers and support for the patient in this regard.

The Safety Plan

The most dangerous time for a battered woman is when she decides to leave her abuser. Ensuring that the patient has an individualized safety plan is therefore a crucial and potentially life-saving step. Although it is the physician's responsibility to make sure a safety plan is developed if disclosure occurs in the health care setting, the actual formulation of the safety plan can be somewhat time-consuming and is best accomplished with the assistance of a skilled social worker, nurse, or battered women's advocate.

The safety plan should include the following elements: emergency procedures, home safety, an abuse prevention order, safety on the job and in public, and logistical issues [32].

Emergency Procedures

Emergency procedures should include a discussion about ways the patient can attain safety during an explosive incident, such as which rooms of the house to avoid (for example, the kitchen, where knives are readily accessible, and the bedroom, where most firearms are hidden and where most sexual assaults occur), how to exit rapidly and safely, and how to alert a neighbor to call the police if an altercation is overheard or if a special code or signal is received.

Home Safety

A discussion about the following issues should be included: changing door locks, installing a caller identification system on the telephone or having an unpublished telephone number, and letting the children know not to unlock the door for anyone, including the batterer.

Abuse Prevention Order

An abuse prevention order, known in some states as an order of protection or a restraining order, is a legal document issued by a court of law, enforceable in most states by immediate arrest for violation. The order is designed to protect an individual from abuse, injury, or threat of injury by an intimate partner or relative. In cases of domestic violence, the abuse prevention order should be carried on the victim's person at all times, and a copy should be kept in a secure location elsewhere. Neighbors should be alerted to the presence of such an order and instructed to contact the police if the batterer attempts to confront the victim or enter the victim's property. The police should be informed of the nature of the call if this occurs.

Workplace Safety

Because safety on the job is another important issue, the abuse prevention order should be written to extend to the victim's work site, and coworkers, supervisors, and company security should be alerted to its existence and provisions.

Logistical Considerations

Discussion regarding a place to which the victim can go that is unknown to the batterer, how to get there, and essentials to have packed (such as money, keys, medications, insurance and other cards, and changes of clothes for the woman and her children) should be included as part of the safety plan.

Primary and Secondary Prevention in the Office Setting

Many ways are available to bring effective primary and secondary prevention into the office practice setting. First, clinical office staff should receive periodic training on the basic dynamics of the abusive relationship, as well as in office screening, triage, and referral. Second, the office receptionist should be provided with telephone numbers of local resources that can be given to patients on request. Third, ancillary staff such as clerks, parking lot attendants, and security personnel should be trained, as appropriate to their position and skill, in basic domestic violence awareness and response. Suspicious situations, such as yelling, pushing, slapping, or other inappropriate behavior in the parking lot or waiting area, should then be reported confidentially to the physician or nurse. Fourth, posters, pamphlets, and other patient education material should be available in the office reception area and in private locations such as bathrooms and examination rooms. Fifth, the physician should invite a discussion with the patient about nonviolent alternatives for the resolution of conflict in the home. These issues should be discussed with male and female patients and can be an important component of creating an atmosphere of primary prevention-oriented health advocacy for all patients.

A strong, consistent, and integrated message that the physician and office staff are knowledgeable and concerned about domestic violence can create a physician-patient atmosphere that comprehensively yet efficiently addresses the issues at hand while respecting the time demands placed on the practicing physician.

Working Effectively with Victims of Abuse while Recognizing the Barriers That Physicians Face

Physicians face many attitudinal and logistical obstacles in approaching the care of battered women [1, 33]. Sugg and Inui [1] determined that the imagery of "opening Pandora's box" was a common reaction of physicians to the prospect of exploring issues of domestic violence with patients. Although these barriers can substantially affect the physician's responsiveness to this problem, they should not pose insurmountable obstacles to working effectively in the care of battered patients. The following are barriers that physicians face and their possible solutions.

The Fantasy of the Perfect Family

Many physicians who themselves have not experienced domestic violence adhere to an idealized vision of the home and have expressed difficulty approaching screening for domestic violence in patients who come from socioeconomic and demographic backgrounds similar to theirs. It is often difficult to acknowledge the possibility of abuse in persons who are so much "like us" because compassionate care requires an empathic response in the physician. Recognition, through education and clinical experience, of the prevalence and spectrum of abuse in different sociodemographic groups can enable the physician to work more effectively and empathically.

The Reality of the Imperfect Patient

Many battered women do not present to the health care setting as "model" patients. The relatively high prevalence of psychological and somatic sequelae of abuse (such as chronic pain symptoms, depression, and alcoholism and other substance abuse), combined with frequent yet often episodic use of health care services, serves to make many battered patients less desirable in medical venues than patients who present for regularly scheduled care on time, have one or a few concrete issues, and rapidly get better with prescribed treatment. In addition, physicians, not unlike other members of society, are subject to stereotyped assumptions regarding domestic violence. The following are examples of such assumptions: Domestic violence is rare; domestic violence may occur but is seen mostly in other physicians' practices; intimate partner abuse does not occur in families that appear "normal"; battered women have brought on the abuse because of their behavior in the relationship; and finally, if battered women don't leave or if they subsequently return to the abuser, the abuse was not very severe or a codependency within the relationship makes the woman seek the abuse. Such stereotyped assumptions can only undermine the ability of the physician to provide optimal care. Recognition of the varied medical and behavioral sequelae of abuse can enable the physician to work more effectively and empathically. Unbiased, data-supported educational initiatives combined with compassionate, non-judgmental attitudes can dispel such value-laden myths. Educational initiatives must encompass all phases of medical training and continuing medical education and should also include training for office staff.

The Physician's Previous Abuse

The physician may have been a victim of child physical or sexual abuse or an adult victim, or perpetrator, of intimate violence. In the study by Sugg and Inui [1], 14% of male physicians and 31% of female physicians acknowledged a personal history of child abuse or of physical abuse as an adult. As professional and personal supports become more available to physicians, their own histories and recovery from abuse can be better addressed, thus enabling improved patient care.

Fear of Offending Patients

Some physicians are reluctant to ask their patients about abuse, fearing they may offend patients by asking about a topic that society considers a private matter, one that should stay "behind closed doors." Most patients are grateful to their physicians who routinely inquire about violence and abuse in relationships and do not consider this line of inquiry to be offensive or intrusive. Addressing issues of violence and abuse is generally welcomed by patients, who look to their physicians for advice and support in areas in which the physician feels competent to engage.

Powerlessness and Lack of Control

Physicians often feel overwhelmed by the size of the problem and helpless in their efforts to be effective in bringing about any type of meaningful change in a battered patient's life. In addition, although willing to screen, identify, treat, and refer victims of intimate partner abuse, many physicians are frustrated with their inability to direct the outcome and with their patients' inability to effect meaningful changes in their life circumstances. The lack of easily identifiable therapeutic tools, combined with the complex medical, social, and behavioral issues at play, usually make an easy diagnosis and quick fix untenable in instances of domestic violence. The ability of the physician to function as a member of a multidisciplinary team, use available community resources, and understand that the most appropriate treatment should consider the patient's individual needs in the context of her own life circumstances is important in addressing the physician's feelings of powerlessness and lack of control.

Lack of Education

Most practicing physicians have received no education in domestic violence during medical school, postgraduate training, or continuing medical education. The lack of basic knowledge and skill in this area is closely related to many of the other physician barriers described above. Domestic violence is only now becoming recognized as a problem that is appropriately addressed in the health care setting and taught in educational venues. Core competency in knowledge, skill, and attitudes in primary prevention and in caring for victims of intimate partner violence should be included in undergraduate medical education and postgraduate training. High-quality, skill-based continuing medical education programs should be available to physicians in practice and encouraged through specialty societies and organized medicine.

Fear of Precipitating More Violence

Given the known increase in danger to the victim when she decides to leave an abusive relationship, some physicians are reluctant to risk doing more harm by advocating on behalf of a battered woman, empowering her to decide to leave, and thus potentially precipitating nonlethal injury or even homicide. Safety planning should be incorporated into the treatment strategy for every current victim of domestic violence. Such safety planning is best done with an expert in crisis intervention in domestic violence, usually a battered women's advocate.

The Tyranny of Time

Time constraints can be a formidable barrier to doing effective work with battered patients. Many physicians feel they have inadequate time to intervene effectively if a patient discloses abuse. Others voice frustration that having to ask about "one more thing" will be too burdensome in a clinical encounter that is already full. Clearly, a crisis situation in domestic violence, similar to a cardiac crisis or the exigencies of dealing with an acutely suicidal patient, needs to be triaged appropriately and expeditiously. Professional and community colleagues who can be contacted rapidly, the availability and use of patient education materials, and the implementation of updated office protocols can minimize the disruption in office routine when a diagnosis of current domestic violence is established. In the setting of routine patient care, questioning about violence in relationships can be easily incorporated into the periodic history and physical examination, along with a message of compassion, empathy, and concern about the issue. This simple message of care can have a tremendously positive effect on the physician-patient relationship overall and may even improve the flow and efficiency of patient care.

Isolation

Physicians who try to provide solo care for victims of domestic violence are doing both themselves and their patients a disservice. This work can be stressful, emotionally draining, and disturbing and should not be under-taken in isolation. Physicians are encouraged to develop a support network in the local community; to share the burden of active cases; and to offer mutual supervision, support, and collegiality.

Office Security and Personal Safety

Although not mentioned as a barrier by the physicians responding in Sugg and Inui's study [1], other physicians have voiced reluctance to ask about or intervene in situations of domestic violence, out of concern for their own personal safety or that of their office staff. I know of no reports of health care workers being threatened, injured, or killed by the partners of patients who are victims of domestic violence. However, the potential risks to office staff must be considered in any potentially volatile situation. The contract of care is between the physician and the patient. When the patient is a victim of domestic abuse, the perpetrator should not be contacted or confronted in the office setting. In addition, training for office personnel on recognizing and responding to domestic violence issues, and in assuring strict patient confidentiality, is encouraged. Emergency procedures should be outlined and practiced in the office setting for potential emergencies in domestic violence, as well as in other situations.

Summary

Top Summary Author & Article Info References

In conclusion, the short- and long-term effects of domestic violence are health care issues that nearly every practicing physician encounters in the course of routine clinical practice. Physicians are now expected to know the basics of recognition and intervention related to primary prevention, early intervention, and crisis care of victims of domestic violence. The importance of routinely integrating questioning about violent conflict and intervention into office practice, particularly in generalist fields such as internal medicine, are important components of the new agenda for health care in the twenty-first century.