by
Ellen Taliaferro, MD
Zita Surprenant, MD, MPH
Intimate Partner Violence (IPV), the psychological, emotional, and physical abuse of your patients by a current or previous intimate partner affects close to four million women a year. A little over a third of these women report violent victimization. Like many other medical conditions, IPV often escalates in frequency and severity the longer it persists. For approximately 1,000 women each year the violence becomes fatal.
Few of us in healthcare are comfortable dealing with IPV. Couple this with the fact that many physicians feel that their patients do not have family violence issues and you end up with a devastating problem that goes unrecognized, unaddressed, and untreated.
The truth remains that IPV presents a major challenge to physicians in every practice setting and specialty, and the after effects of violence and abuse cast a long shadow on the patient’s current and future health.
Early recognition of IPV and an appropriate response to IPV goes a long way to getting patients the help they need to be safe and escape on-going injuries and illness. In addition, a valuable added benefit occurs when the psychological and physical trauma of the abuse is addressed, laying the groundwork for the patient’s improved health and well being.
IPV problems can appear at any moment in any practice setting. In light of this fact, physicians and healthcare providers can improve patient care of IPV victims by implementing 10 Action Steps in their clinical settings.
Section One of our new book, Respond to Intimate Partner Violence—10 Action Steps You Can Take to Help Your Patients and Your Practice, provides guidance for the recognition and detection of IPV in the practice setting. Section two stresses appropriate response to the identification of IPV by putting into place 10 action steps.
Action Step No. 1: Respond Effectively to Patients Who Disclose Violent Relationships
When a patient tells you that IPV complicates her life, you have a unique opportunity to help her improve her health and well-being. Support her in making changes by validating the difficulties and challenges she is experiencing, as well as her need to make changes.
By validating victims and survivors of IPV, you give your patients a tonic more powerful than any prescribed drug. Validation occurs through therapeutic messages, listening, and providing supporting materials.
Some therapeutic messages that you tell the patient bear repeating several times during your time with the patient. Chief among these:
• “You do not deserve to be hurt, no matter what.”
• “You are not alone; help is available.”
Listening non-judgmentally is a therapeutic message in itself. Once you have validated your patient, you have her trust and can move to the next step in her care.
Action Step No. 2 Respond to Your Patient’s Safety Needs:
Start by determining how safe your patient is right now. There are numerous safety assessment tools you can us. One simple one is the Physical Abuse Ranking score. Ask about these ten things:
1. Throwing things, punching the wall
2. Pushing, shoving, grabbing, throwing things at the victim
3. Slapping with an open hand
4. Kicking, biting
5. Hitting with closed fists
6. Attempted strangulation
7. Beating up (pinned to wall/floor, repeated kicks, punches)
8. Threatening with a weapon
9. Assault with a weapon
If your patient’s abuse-related incident ranked higher than five on this scale, your patient can be in extreme danger. However, even if the abuse ranks low on this scale, your patient may still be in danger. Any patient who feels in danger should be considered to be in danger.
Safety planning for your patient should be tailor made to conform to her needs. For instance, she may elect to stay in her relationship with her batterer because she feels that is safer than leaving at this time. Regardless of whether of not your patient elects to leave or stay with her batterer, she must not leave your clinical setting without a plan in place.
Action Step No. 3: Manage Your Patient’s Referral Needs
Services available to help patients differ in each community. However, a fast call to the National domestic violence hotline, 1-800-799-SAFE, provides you with local resources that your patient can access. Be sure and identify yourself as a provider at the very beginning of the call.
Most patients dealing with the presence of intimate partner violence in their lives don’t need to be admitted to the hospital. If your patient has medical or mental health needs that require admission, and her perpetrator remains free or poses a threat to your patient, consider admitting her as a Jane or John Doe patient. Note that HIPAA provides that patients can request not to be listed in the health care facility directory.
Action Step No. 4: Document Your Findings
Good documentation builds a bridge of communication among healthcare providers attending the patient and also assists when community advocacy and legal referrals are indicated. When taking care of victims of IPV, the three main modes of documentation consist of:
• Charting
• Body maps
• Photo documentation
Action Step No. 5: Meet Your State and Local IPV Reporting Requirements
Mandatory injury reporting requirements vary considerably from state to state. To provide effective IPV intervention, you need to understand your state and local reporting laws, procedures, and the methods of enforcement, whether the issue is IPV, child abuse, elder abuse, abuse of someone with a disability, or assault involving weapons.
Specific information about state reporting laws can be found at the www.endabuse.org website.
Action Step No. 6: Respond to Your Patient’s Stage of Change
Change is not easy. Leaving an abuser or staying in a relationship with new family dynamics often represents a major life change. You can best help your patient to bring about necessary changes in her life by understanding that change occurs in stages and that relapse is a normal part of the change process.
Action Step No. 7: Address IPV in Special Populations
There can be additional barriers, special needs, and safety issues when working with IPV victims across age groups, gender, sexual orientation, and different cultures. You can best help individual patients in each of these groups by understanding the special needs each group has. For instance, a male victim of IPV struggles with issues separate from a teen-age girl being abused by her partner or an elderly widow who remarries and then finds herself a victim of abuse.
Action Step No. 8: Address Special Clinical Situations Involving IPV
In addition to separate populations, special clinical situations arise when treating IPV patients. For instance, the IPV victim and her perpetrator may both be your patient. Or your patient may be suicidal. Another special situation arises when her abusive partner manually strangled your patient during an assault.
Action Step No. 9: Develop a System for Addressing IPV in Your Practice Setting
You need a team approach to lay the groundwork for effective IPV intervention in your practice setting. Two critical ingredients set the stage for success:
• Provide training for your staff to understand IPV and to respond to it
• Designate a practice setting “IPV Champion” who becomes your local expert on policies, procedures, and local resource coordination.
Action Step No. 10: Respond to Abusers
Although your first concern must be the safety of the IPV victim, who is not safe until the abuse and battering stops, you must also care about your patient’s abuser. Caring about IPV abusers can be a means of ending the abuse and ensuring the victim’s safety. Remember, even when victims leave their abusers and are safe, there is a high probability that their untreated abuser will victimize a new partner.
You can learn more about identifying IPV in your practice and preparing your practice setting for effective intervention in the book, Respond to Intimate Partner Violence—10 Action Steps You Can Take to Help Your Patients and Your Practice. The accompanying CD-ROM in the book contains resources such as medical record forms, patient handouts, and even a staff-training guide. The book can be ordered from the Virtual Lecture Hall of Medical Directions, Inc. by visiting their website or through Amazon.com. Online training with CME credits featuring the information in the book can also be found at www.vlh.com.
Physicians and health care providers have a unique opportunity to identify and intervene with IPV in their practice settings. Doing so can save lives, promote their patients’ health, and enhance their patients’ well being. Los Angeles physician Bruce B. Ettinger sums this up quite well, “set up a response system if one does not already exist, and take the risk and ask questions. The reward will equal anything you have ever done in medicine. You will save a life.”
Author's note: You have permission to copy this article for distribution for web and print publications as long as you do not change content or remove hyperlinks in your online distribution. Notification of your use of the article is appreciated. For questions or to arrange for one of the authors to speak at your event, please contact DrT at: DrTspeaks@gmail.com.
