Back to Front PageVOLUME 6, NUMBER 4

For Domestic Violence Victims, the Doctor Is Not Always In

by Barbara A. Gabriel

In Dr. Nicolaidis' educational videotape, domestic abuse survivors stress the importance of physician compassion and empathy.

Studies estimate that some form of domestic violence occurs in 4 to 6 million intimate relationships each year in the U.S., making it the most common cause of nonfatal injury to women in this country. Battered women -and sometimes men-suffer not only from life-threatening physical injuries, but also from a host of related illnesses, including depression and post-traumatic stress disorder.

Yet even though domestic violence is widely recognized as a chronic health condition that at its worst is lethal, training on its detection and treatment sometimes remains marginalized in medical education.

According to the AAMC Curriculum Directory, all U.S. accredited medical schools provide some teaching about domestic violence. But a study published in 1998 in the American Journal of Preventive Medicine found an average of only two hours was reserved for such teaching. The study's authors, led by Elaine J. Alpert, M.D., also found that this instruction occurs predominantly within the first two years of medical school, before students begin to "integrate and apply knowledge of medical and social problems to the clinical assessment and care of patients."

Research also indicates that practicing physicians fail to adequately screen patients for domestic violence. A study appearing in the Journal of the American Medical Association in August 1999 found that while 79 percent of primary care physicians surveyed screened injured patients for domestic violence, only between 9 and 11 percent of patients were screened during their first doctor's visit, periodic checkups, or visits for prenatal care.

Lead author Michael A. Rodriguez, M.D., assistant professor in the Department of Family and Community Medicine at the University of California, San Francisco, concludes that primary care physicians are missing important opportunities to detect domestic violence.

"There's a particular responsibility on the part of primary care physicians to screen for intimate partner abuse," says Dr. Rodriguez. "They have deeper relationships with their patients than other physicians, and are more likely to be in positions to notice that something is wrong."

Dr. Rodriguez cites lack of physician training as a formidable barrier to standard domestic violence screening. "Physicians are reluctant to address intimate partner abuse because of their discomfort with the subject, a sense of powerlessness, and the concern that bringing attention to it will open a Pandora's box that they are ill-equipped to deal with."

Dr. Rodriguez recommends that domestic violence training be both systematically integrated into medical school curricula and targeted in continuing medical education. Indeed, his study found that physicians who had received CME on the subject within the past three years were more likely than their counterparts without recent training to share information about shelters with patients, report violence to the police, and ask about the presence of guns in the home.

Julie A. Jonassen, Ph.D., associate professor of Physiology at the University of Massachusetts Medical School, is taking an active role in incorporating domestic violence training into her medical school's curriculum. "Physicians have a crucial role in the prevention of and intervention in domestic violence," Dr. Jonassen says. "Studies suggest that women are more likely to disclose domestic violence to their doctors than to other professionals, including police officers, social workers, and ministers."

Dr. Jonassen has developed a "domestic violence interclerkship" (DVI) at the University of Massachusetts. Initiated in 1995 and required of all third-year medical students, the multidisciplinary training aims to provide students with a set of skills they can immediately put into clinical practice.

Dr. Jonassen has conducted follow-up studies that indicate a high level of retention of the knowledge and skills taught during the DVI. "About 75 percent of my former students say that they've screened patients, and about 40 to 50 percent say they've uncovered at least one case of abuse," she says.

In spite of the DVI's documented effectiveness, a growing number of interclerkships and a crammed medical curriculum have forced Dr. Jonassen to scale back the length of her course from three days to one. She divides this precious time into a mixture of lectures, workshops, and small group exercises, ending with a keynote address by a domestic abuse survivor. "Hearing directly from a former victim has a big impact on our students," she explains.

Christina Nicolaidis, M.D., has tapped that power of personal testimony to produce an instructional video on domestic violence. Titled "Voices of Survivors: Domestic Violence Survivors Educate Physicians," the 30-minute documentary features interviews with 21 survivors who share their own experiences within the health care system and suggest to physicians effective methods of dealing with battered patients.

Dr. Nicolaidis, an associate professor of Internal Medicine at Oregon Health Sciences University, explains that the most important concept the video conveys is that ending a domestic violence situation is neither a single event nor the sole responsibility of the physician who detects it. Rather, it is a process that should be controlled by the victim and supported by her physician. "Nobody expects a physician to take care of the whole situation," she says. "Our job is to detect it, to be there to support the person if they go through a complicated series of referrals, and to connect them with people who can help." "Survivors express a surprising degree of faith that physicians can make a difference," she says. "Addressing domestic violence may be one of the most important contributions we can make to the health of our patients and their families."

Information: Dr. Jonassen, (508) 856-5808; Dr. Nicolaidis, (503) 494-6550. To order the "Voices of Survivors" tape, call (800) 523-1546, ext. 2600.

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