AAFP President Wanda Filer, M.D., M.B.A., speaks about preventing domestic violence and abuse during a panel discussion hosted by Futures Without Violence and the National Health Collaborative on Violence and Abuse.
When she was just three years out of residency, AAFP President Wanda Filer, M.D., M.B.A., saw a young mother who brought her newborn baby in for a wellness visit. Filer asked all the important questions a physician should, except one.
It's what they didn't discuss that changed Filer's entire perspective about being a family physician, she said May 10 during a briefing on Capitol Hill. The event, Building Partnerships to Reduce Violence and Abuse and Improve Health Care Across the Lifespan, was hosted by Futures Without Violence and the National Health Collaborative on Violence and Abuse. The AAFP is a member of the collaborative.
Filer said she and the mother talked about breastfeeding and immunization but not about the mother's physical safety. Filer was not aware that the woman was in an abusive relationship. Just a few weeks after that visit, the woman was dead. Her husband had killed her, along with her two older children and two relatives. Only the infant survived. Filer hadn't been taught in residency that homicide is the leading cause of death for women within one year of giving birth. It was more than 20 years ago, and not many physicians had this knowledge.
- AAFP President Wanda Filer, M.D., M.B.A., recently spoke about domestic violence and abuse at an event on Capitol Hill.
- She suggested techniques physicians can use to draw out patients who are experiencing abuse.
- New payment models could allow for enough time for patients and physicians to discuss violence and other life-saving issues.
Filer said she and a colleague, who was the patient's primary care physician, retraced their steps, wondering what they missed.
"I went on a personal journey," Filer told those who attended the recent panel discussion. "I asked, 'What could I have done differently?'"
Now when Filer meets patients, she looks for signs of domestic abuse and asks about safety conditions inside the home. Over the years, she has shared her experiences with numerous family physicians, and some tell her these conversations helped them become more aware of their patients' social needs.
"I don't have to sell this anymore," she told the audience. "Now we have to do something about it. The realization is there."
Other panelists emphasized this reality with details on the prevalence of violence against women and children and measures that may counter the trends. For instance, 20 percent of women experience some form of violence during their lifetime, and one in 11 is a victim of rape. On campuses, 20 percent of women are victims of sexual assault.
Fifty percent of children experience at least one adverse event such as abuse, neglect or household dysfunction, and 23 percent experience two or more. When children report four or more adverse events, studies indicate they are more likely to suffer from emotional problems regardless of other factors.
"As a nation, we are not doing enough to move the needle on violence against women and children," said Michael Lu, M.D., M.S., M.P.H., an associate administrator for the Health Resources and Services Administration.
One thing physicians can do, Filer said, is to "dig deeper" for reasons when patients don't schedule needed colonoscopies or Pap smear tests. The digging may be welcome. Filer once asked an 86-year-old woman if she experienced any physical abuse and the patient thanked her because it was the first time she had been asked that.
Filer said conversations about domestic violence should include discussion about the presence of guns in the home, an issue that came to the forefront when Florida enacted a law that prohibits physicians from discussing guns with patients.
"In every state but Florida, we can do this," Filer said. "I have lost patients to gun violence. You cannot gag your health care workers when you are talking about saving lives. I need to be able to have that conversation."
If a patient shows signs of domestic abuse, Filer will make a referral to a local domestic violence agency and, possibly, a behavioral health specialist who is knowledgeable about trauma and can connect the patient with support. Age should not be considered a factor in consulting patients about abuse, said Filer, because some elderly patients are subjected to physical abuse by their own children.
Lisa James, director of health for Futures Without Violence, echoed this advice.
"Abuse does not end at age 60," said James. "We want to address abuse at the end of the life span."
Futures Without Violence supports several pending bills related to this issue,(www.futureswithoutviolence.org) including one that aims to renew an early childhood home visiting program, another that seeks to reauthorize the Family Violence Prevention and Services Act, and a third seeking funding for the Elder Justice Act.
Filer said education on domestic abuse should be integrated into all medical schools' curricula and residencies to prepare physicians to deal with patients who show signs of abuse. As a former obstetrics professor at the University of California, Los Angeles, David Geffen School of Medicine, Lu said the school did not train residents adequately about domestic violence screening and awareness.
Many physicians do not address domestic violence during office visits because of time limitations. Being paid on a fee-for-service basis puts physicians on a "hamster wheel" where they often do not have enough time in the day, Filer said. She is hopeful that new payment models will give patients and physicians more time to discuss these and other life-saving issues.
Because 40 percent to 50 percent of adolescents are touched by some form of violence by the time they reach college, panelists said early public education also should address violence and sexual abuse openly. In some communities, however, such efforts are under threat.
Beth Kotarski, M.S.N., C.R.N.P, director of university health services at Carnegie Mellon University, spoke about a school district in suburban Philadelphia where health education emphasizes abstinence-only relationships and just a basic understanding of bodily functions.
"You take away a lot of power by taking away knowledge," she said.
Medical professionals should also consider changing the language they use with patients, said Arlene Bradley, M.D., of the American College of Physicians. Instead of saying "victim" and "perpetrator," she suggests referring to individuals who "use violence" and those who "experience violence." This change could create a more comfortable environment for patients to discuss their experiences, she said, noting that many individuals who abuse spouses or children may have experienced abuse themselves.
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(March 15, 2014)