Am Fam Physician. 2016 Oct 15;94(8):600-605.
In this issue of American Family Physician, DiCola and Spaar give pragmatic guidance to family physicians on their role in responding to patients who are experiencing intimate partner violence (IPV).1 Their approach accords with the U.S. Preventive Services Task Force recommendation to screen all women for IPV. The United States is one of the few countries with a policy of screening for IPV. Guidelines from the United Kingdom's National Institute for Health and Care Excellence2 and the World Health Organization3 recommend a low threshold for physicians to ask about IPV, but do not recommend routine screening. The evidence for screening in health care settings is contradictory, hence the discrepancy between the systematic review underpinning the U.S. Preventive Services Task Force guidelines4 and the Cochrane review on which the National Institute for Health and Care Excellence guidelines are based.5,6
I propose that we move beyond this debate, particularly in the context of family medicine, and focus instead on action that will protect the safety of patients experiencing IPV. My rationale for this proposal is twofold.
First, screening programs are not all that different from targeted inquiry approaches. We know that screening programs increase disclosure of IPV in health care settings. We also know that training family physicians to ask about IPV, particularly when there is a referral pathway to further support the patient, also increases disclosure.7 There are no head-to-head trials of screening vs. clinical inquiry (or active case finding), so we do not know which is more effective. Given that even in trials screening by physicians is only partial, in reality, the operational difference in the family medicine clinic between an IPV screening program and a targeted clinical inquiry program is likely to be minimal. Physicians do not implement screening not only because of time constraints, lack of training, and discomfort with asking about abuse, which would affect any IPV identification method, but also because they are skeptical about the evidence base.8
Second, the IPV screening vs. active case finding debate is a distraction for researchers, systematic reviewers, and physicians, because it focuses attention and resources on what is only the first step in an effective (and safe) response to survivors of IPV in clinical settings. The ensuing steps after a patient has disclosed abuse to a physician (or physician's assistant or nurse) are as important as eliciting disclosure, regardless of the identification method. These steps include the physician giving an appropriate and validating response, checking for safety, offering referral to IPV support agencies, facilitating uptake of that referral (i.e., more than just offering a list of agencies), and offering ongoing physician contact.
What is the thread that ties effective identification of IPV survivors to effective management? Training. Given the absence or low profile of undergraduate or postgraduate medical training on IPV, how can we expect physicians and other clinicians to engage with the issue? They often do not understand the epidemiology of IPV, its coercive reality, the entrapment of survivors, and the severe safety risks, which may inhibit disclosure of the abuse or use of support services. Asking about IPV in a family medicine setting, via a screening tool or in the course of taking a clinical history, requires training and practice. A systematic review of nine trials of IPV training interventions for physicians showed that only multifaceted physician training that combined education with system support interventions changed physician behavior related to IPV. System support activities included displaying posters and brochures about violence in waiting areas, and providing prompts to physicians, checklists in medical records for IPV diagnosis, and information on accessing services and referral for patients.
In the United States and internationally, we need to prioritize effective IPV training of physicians and other clinicians, whatever guidelines we use to identify IPV survivors. If they do not exist already, we need to establish explicit referral pathways to IPV advocacy support, which may be outside of health care organizations in the social care or community nonprofit sectors.
Physician offices may be one of the few safe spaces for patients to disclose their abuse. We know that survivors want us to ask about IPV and to respond appropriately and safely.9 Training and system support will allow us to do that.
REFERENCESshow all references
1. DiCola D, Spaar E. Intimate partner violence. Am Fam Physician. 2016;94(8):646–651....
2. National Institute for Health and Care Excellence. Domestic violence and abuse: multi-agency working. February 2014. https://www.nice.org.uk/guidance/ph50. Accessed June 29, 2016.
3. Feder G, Wathen CN, MacMillan HL. An evidence-based response to intimate partner violence: WHO guidelines. JAMA. 2013;310(5):479–480.
4. Nelson HD, Bougatsos C, Blazina I. Screening women for intimate partner violence and elderly and vulnerable adults for abuse: systematic review to update the 2004 U.S. Preventive Services Task Force Recommendation. Rockville, Md.: Agency for Healthcare Research and Quality; 2012. http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0046296/pdf/PubMedHealth_PMH0046296.pdf. Accessed June 29, 2016.
5. O'Doherty L, Hegarty K, Ramsay J, Davidson LL, Feder G, Taft A. Screening women for intimate partner violence in healthcare settings. Cochrane Database Syst Rev. 2015;(7):CD007007.
6. British Columbia Centre of Excellence for Women's Health. Review of interventions to identify, prevent, reduce and respond to domestic violence. April 2013. https://www.nice.org.uk/guidance/ph50/evidence/review-of-interventions-to-identify-prevent-reduce-and-respond-to-domestic-violence-430413229. Accessed June 29, 2016.
7. Feder G, Davies RA, Baird K, et al. Identification and referral to improve safety (IRIS) of women experiencing domestic violence with a primary care training and support programme: a cluster randomised controlled trial. Lancet. 2011;378(9805):1788–1795.
8. Feder G, Arsene C, Bacchus L, Dunne D, Hague G, Kuntze S, et al. How far does screening women for domestic (partner) violence in different health-care settings meet criteria for a screening programme? Systematic reviews of nine UK National Screening Committee criteria. Health Technol Assess. 2009;13(16):iii–iv, xi–xiii, 1–113.
9. Feder GS, Hutson M, Ramsay J, Taket AR. Women exposed to intimate partner violence: expectations and experiences when they encounter health care professionals: a meta-analysis of qualitative studies. Arch Int Med. 2006;166(1):22–37.
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