Screening for Abuse May Be Key to Ending It

[Guest guest]

From yesterday's (May 20, 2008) Health Update of The New York Times

Where ABA is linked to justness and proper health care, among other

things related to teaching.

What isn't ABA is relatively abusive and unhealthy, where ABA answers

to reason and conscience, of Communication, of Understanding More (of

Analysis?) Of all that there is and can be

My sense of it.

Enjoy.

http://www.nytimes.com/2008/05/20/health/20abus.html?

nl=8hlth & emc=hltha1

May 20, 2008

Screening for Abuse May Be Key to Ending It

By ERIN N. MARCUS, M.D.

The silver-haired woman greeted me at the clinic door, one arm

suspended in a bright blue sling.

This wasn't her first visit. In the preceding few months, she had

come to the clinic twice with assorted aches and inexplicable pains.

Now her husband had broken her arm, and the reason for those visits

had become glaringly obvious: he had been hitting her.

And the domestic violence screening question I'd asked months before —

nestled between queries about smoking and seat belts — seemed to

have been spectacularly ineffective, since she'd answered " no. "

When I had asked about violence at home, I had been following

guidelines set by the surgeon general and many professional groups,

including the American Medical Association. Those who support routine

questioning say domestic violence is as or more common in women than

many diseases for which doctors regularly check, including breast and

colon cancer, and its health risks are well documented.

Despite these recommendations, screening for domestic abuse in

seemingly healthy women is nowhere near as widespread among doctors

as testing for breast cancer or high cholesterol.

Some physicians see domestic violence primarily as a criminal justice

issue, and take umbrage at being expected to delve into a difficult,

messy topic when they already have to screen for many other

conditions and diagnose complicated diseases in the span of an ever-

shorter visit.

In a recent nationwide study of nearly 5,000 women, only 7 percent

said a health professional had ever asked them about domestic or

family violence. When surveyed, doctors often respond that they don't

ask such questions because of a lack of time, training and easy

access to services that help these patients.

Some have reported that they worry about offending patients and

believe asking won't make any difference.

" Just like anybody else, doctors avoid things they may have

discomfort doing, " said Dr. , a researcher and

family practitioner at the University of California, Los

Angeles. " There's also an expectation on the part of some folks that

once we identify abuse she should just walk away, and frustration

when she doesn't. "

Dr. and other experts say that urging an abused patient

simply to leave may not be realistic or safe, for several reasons:

The risk of being murdered is highest at the time one leaves, the

woman may depend on her partner for food and shelter, and patients

may not respond well to a doctor who dictates what to do.

They also say the best way to ask about such abuse is in a private

place, with no family members present, as part of the routine patient

history. If the patient says she has been battered or threatened at

home, experts recommend that the doctor offer empathy, tell her

what's happening is wrong, document her story in the medical record

and provide her with information on places to go or refer her to

someone who may be able to help, like a social worker.

Barbara Gerbert, director of the Center for Health Improvement and

Prevention Studies at the University of California, San Francisco,

said that while some women might deny domestic violence at first, the

question itself could have a profound effect: many women remember

that their doctor asked and eventually, even years later, reveal

their secret.

" Just by asking, you may be planting a seed for change, " she said.

Numerous studies indicate that doctors ask about domestic violence

poorly, however, and don't handle it well when they do get a yes

answer.

Felicia M. Frezell, 34, an office manager in Omaha, told me recently

that she visited her doctor's office many times with her five

children during the 15 years she lived with her ex-husband, who was

convicted in 2005 of raping her. She said that even though she often

had bruises, no one ever asked her why — until she asked her doctor

to look at her swollen black eye and told him her husband had hit

her.

" He just said, `You'd better get out of that situation' and left it

at that, " Ms. Frezell said, and added: " Looking back, I didn't know

the resources that were out there. The doctor's office is a good

place to go because it's neutral and it's confidential. It's not like

telling your husband you're going to the police department. "

According to the Bureau of Justice Statistics, from 2001 to 2005 (the

last year for which statistics are available) there was an annual

average of nearly 511,000 violent assaults against women — and

105,000 against men — by a spouse or intimate partner, about half

resulting in physical injury.

Despite such numbers, the United States Preventive Services Task

Force concluded in 2004 that although clinicians should " be alert "

for signs of violence, there was insufficient evidence to recommend

for or against screening asymptomatic patients for domestic abuse —

mainly because of a dearth of large-scale scientific studies looking

at this question.

While many researchers say more money is needed to pay for such

studies, some say the analogy to routine screening misses the point.

" Trying to equate it to a Pap smear is the wrong paradigm, and it's

just irrelevant, " said Dr. Nicolaidis, a general internist

and researcher at Oregon Health and Science University. " It's not a

test you can just check off. "

" The reasons to ask, " she continued, " are to educate a patient and to

open the door so that the patient knows she can come to you. It's

part of developing a real relationship with your patient. Over time,

you might be able to uncover the abuse and improve her safety, but

you also might better understand why she's having her symptoms and

how to better approach her self-management of her illness. "

Abused women are at increased risk of chronic pain, depression,

anxiety and alcohol and substance abuse, and they can have problems

taking their medication correctly and getting to appointments. In one

recent study, women who said they had been abused within the past

year were more likely to have partners who interfered with their

medical care.

Seven years ago, the Institute of Medicine, which advises the federal

government, issued a major report on the training of health workers

on family violence. The report concluded that such violence " was not

a consistent priority " in health workers' education and recommended

that the Department of Health and Human Services establish education

and research centers in family violence.

By unhappy coincidence, the report was unveiled at a news conference

on Sept. 11, 2001, and has since " collected dust, " said one of the

authors, Felicia Cohn, who now directs medical ethics at the

University of California, Irvine.

" Certainly other issues took precedence at the time, " Dr. Cohn

added, " but the continuing inattention is both inexcusable and

embarrassing. This is a public health pandemic with immense health

care implications. "

For my silver-haired patient — and other women I see at the clinic

where I work — there have been no simple answers. I keep the

telephone numbers for a local women's shelter and the police

department's domestic violence unit in my lab coat pocket. And I keep

asking the question, so my patients know there's a place they can

turn.

N. Marcus is a general internist and associate medical director

of the Institute for Women's Health at the University of Miami

School of Medicine.

End.

Screening for Abuse May Be Key to Ending It?

It certainly wouldn't " hurt, " to Communicate, thereof. I was

thinking this also has " special " relevence to our children, as well.

Some people just don't seem to want to do what is more " reasonable "

for their/our children, thereof, of Understanding More, of the

feeling/s, thereof? (Of ABA, thereof?) I sort of mark that as

abusive, of relatively " unreasonable, " thereof, to a matter of

degree, where we are all somewhat responsible, thereof. So the

kettle ain't entirely " shiny silver " . It could be? .. . More so,

thereof, I Feel as understand

We have to get off the kick (habit?) that abuse is only what

the " other " does, relative to our trying to understand more of All,

thereof, keeping in mind that some things are more abusive than

others? .. . Hello? In bringing all abuse under control to be

minimized if not eliminated, thereof, is my sense of It, and what we

are or should be trying to do, of what we do if not what ABA is very

much about to " me, " as an Individual, " first, " thereof

Crank It [ABA] Out in that respect? .. .

Please do.

It's " you " I care about for " my " self, thereof.. . (I like you that

much.