Original Article: Intimate Partner Violence

Issue Date: October 15, 2016

Available online at: https://www.aafp.org/afp/2016/1015/p646.html

To the Editor: We appreciated Drs. DiCola and Spaar's update on intimate partner violence (IPV). The critical update of our 2011 review of this topic in American Family Physician¹ noted new evidence supporting screening women of childbearing age for IPV, leading the U.S. Preventive Services Task Force to move from a finding of insufficient evidence to moderate certainty that screening is effective.² Primary care must now meet the challenge of operationalizing this recommendation and continuing to push toward a more holistic approach to trauma-informed care.

One obstacle to moving forward has been the time burden on physicians to effectively respond to IPV disclosures. Our 2014 systematic review, however, noted that effective interventions are delivered by nurses, social workers, advocates, and educators providing support, education, safety planning, problem solving, and resource navigation that requires only minutes to hours of time.³ With adequate support, primary care physicians themselves do not need to shoulder the full burden of IPV response. However, principles of trauma-informed care require that physicians be attuned to the possibility that past or current trauma may impact patients' health and health care.

For the field to reach its full potential in primary care, the next steps will need to be built on an understanding of the experience of trauma across the patient's life span. Stressors experienced during childhood increase the lifetime risk of risky behaviors, revictimization, and poorer health outcomes. A trauma-informed approach historically focused on secondary and tertiary responses would also embrace approaches to primary prevention charged with not only engaging survivors of abuse and adversity, but also the potential perpetration of abuse and violence among our patients.^4,5

In Reply: We appreciate Drs. Cronholm and Dichter's response to our IPV update. Many family medicine practices have embraced a team-based approach, in which physicians are able to focus their time and energy on addressing the complex ways trauma affects patients' health and on primary prevention. It is still important to recognize, however, that family physicians outside of academic medical centers and large health networks have limited resources. Many times, the “team” consists only of the physician and a small office staff. Even in this setting, it is important for medical education to include the practical details of screening and intervention, along with the ongoing paradigm shift toward recognizing the effects of trauma across the life span and across the families and communities we serve. What is most important is that the question is asked, rather than who asks it.