Although evidence indicates interventions in physicians' offices can break the cycle of intimate partner violence (IPV), a number of barriers are keeping many physicians from screening their patients. But, curbing the rate of abuse is of paramount importance, and physicians are key to making that happen, according to F. David Schneider, M.D., M.S.P.H., the AAFP liaison to and past chair of the National Health Collaborative on Violence and Abuse (NHCVA).
"The premature morbidity and mortality that occur because of violence is just incredible," Schneider told AAFP News Now. "If we wiped out childhood adversities, sexual assault and domestic violence, we would probably wipe out -- or at least significantly delay -- a third of all health care costs in the United States."
According to the U.S. Preventive Services Task Force (USPSTF), the myriad long-term effects of IPV include, but are not limited to,
- unintended pregnancy;
- preterm birth;
- posttraumatic stress disorder (PTSD);
- substance abuse;
- suicidal behavior; and
- increased rates of chronic pain, neurological disorders, gastrointestinal disorders and migraine headaches.
- Intimate partner violence (IPV) negatively affects the long-term health of its victims.
- Although evidence indicates office interventions can break the IPV cycle, many physicians don't screen patients because of a lack of education on how to screen and respond, as well as the disincentive created by the lack of a preventive service procedure code specific to violence screening and response.
- Futures Without Violence provides a free family violence screening toolkit for physicians that addresses these issues.
On the positive side, recent recommendations by the AAFP and USPSTF have opened the door to screening all women of childbearing age for IPV, regardless of symptoms. For women who screen positive for IPV, the AAFP and USPSTF recommend that clinicians provide or refer them to intervention services. But unfortunately, said Schneider, recommendations, by themselves, are not enough to change practice.
"There's nothing that says physicians have to include this service as a routine screening exam," he said. "When someone comes in for a wellness visit or a physical exam, we do the things we think are age-appropriate, and, as much as we can, we have those conversations with the patient.
"Then we do a colonoscopy or a Pap smear or a mammogram, follow up with a physical exam and charge a preventive code, but there's no procedural (CPT) code specific to domestic violence counseling."
Schneider, who also is professor and chair of the Department of Family and Community Medicine at Saint Louis University in St. Louis, Mo., said that although the lack of a global charge for preventive services is one part of the problem, the bigger issue is insufficient education about the issue.
"I think most physicians are reluctant to get into (screening for domestic violence) because, if we find it, many of us are inadequately trained to deal with it," said Schneider. "I believe that's a real barrier to getting physicians to actually ask the questions."
Fortunately, he added, educational tools provided through Futures Without Violence(www.futureswithoutviolence.org) (FWV) can help physicians explore and respond to IPV in their patients.
"The challenge is simply making people aware (the tools) are out there," Schneider said.
FWV Director of Health Lisa James said family physicians and other health care professionals have an absolutely critical role in stopping domestic violence by asking questions in a nonjudgmental way, offering support and resources, and providing referrals -- whether to the National Domestic Violence Hotline http://www.thehotline.org or to a local agency -- to their patients.
"Physicians truly can make a difference," she said. "They may be the first person to reach out to that patient, break down that isolation and offer support."
James said FWV offers an online family violence screening toolkit(www.healthcaresaboutipv.org), Health Cares About IPV, to help family physicians and other health care professionals become more comfortable working IPV screening into their practice.
According to James, the Getting Started(www.healthcaresaboutipv.org) resources shown on the Health Cares About IPV website include all of the protocols needed to create a "systems response" to IPV and family violence. The website's How to Screen(www.healthcaresaboutipv.org) section features a critical list of free tools to support screening and counseling education.
"The How to Screen section walks physicians through the nuts and bolts of how to do this," James said. "It will also link them up with our brochures, which are designed to help providers start the conversation about violence, as well as give patients the materials they need regarding the connection between violence and health."
"There's a lot of research that shows that screening -- directly asking about family violence -- increases identification," said James. "Additional studies demonstrate that when a provider asks (about family violence) and offers information and referral, patients are more likely to pursue an intervention.
"In one such study, women who talked to their health care provider about abuse were four times more likely to use an intervention.(www.ncbi.nlm.nih.gov)"
Schneider, who also helped found the Academy on Violence and Abuse(www.avahealth.org), said educating young health professionals about the intersection of violence and health -- especially demonstrating how family physicians and other health professionals can best intervene -- is important.
"All of us can have the opportunity to intervene, but we need to know we're prepared," he said.
In his own practice, Schneider explained that he works screening into the fabric of the office visit, asking questions while he's taking a history or doing the physical exam.
"I try to get a good context for what the patient's life is like, and we talk about what goes on at home," he said. "I often ask, 'What happens when you argue?' because everybody argues, and I want to know how it affects the relationship. I leave it as an open-ended question to get a gauge for the quality of the relationship and the ability to cope."
Although rare, Schneider said treating both the abused and abuser can present a "sticky" conflict.
"People never come out and say, 'Oh yeah, I hit my wife,'" he said. "But when I have encountered perpetrators, I often find they turn it around as best they can to make themselves seem like the victim. So when I have men tell me they've been victimized by their spouse, that's when my antennae go up."
More commonly, Schneider said, he deals with someone who has been a victim of violence in a past relationship, not the current one. Of course, that doesn't mean an intervention is unnecessary.
"What you're really dealing with here are the sequelae of violence -- depression, anxiety disorders, PTSD, high-risk behaviors, smoking, drinking and that sort of thing," he said. "You've got to figure out what each individual person is willing to do to make him- or herself healthier. So you can do brief interventions in the office, because they've been shown to work quite well, but those patients are not necessarily a one-time thing."
Both Schneider and James said an emerging body of evidence -- all of which was reviewed by the USPSTF in making its IPV recommendation -- shows that screening results in improved health, as well as decreased violence.
"Those are the really exciting studies coming out," James said. "We know that by asking and offering a brief intervention, researchers are seeing lower rates of depression and self-reported violence, as well as lower rates of other negative health consequences, such as poor birth outcomes and poor reproductive outcomes. They are also reporting improvements in mental health and safety."
Of all the tools available, James said she believes the most useful for family physicians may be the screening cards and posters(secure3.convio.net) available free to all health care professionals from the FWV website.
"I would order those cards, as well as a few posters, and hang them up in my setting and start offering the cards to every patient who comes in, as a means for starting the conversation. They are free of charge and they give the physician the language to do this, as well as offering the patient the language to take with them, as well as the resources, if he or she needs them."