This interactive Florida Physican Ebook contains 6 hours of continuing education. To complete click the Complete Your CE button at the top right of the screen.
Florida Continuing Medical Education
FLORIDA MEDICAL LICENSURE PROGRAM MANDATORY CME REQUIRED FOR FLORIDA LICENSE RENEWAL ENCLOSED PROGRAM SATISFIES: • 2 HOURS Board-Approved Controlled Substances/Opioids • 2 HOURS Medical Errors • 2 HOURS Domestic Violence
Need to complete the DEA’s new one-time MATE requirement? See inside for more details.
In support of improving patient care, NetCE is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.
CME FOR:
AMA PRA CATEGORY 1 CREDITS ™
MOC STATE LICENSURE
CME DEADLINE: 1/31/2027
AVAILABLE ONLINE AT: FL.CME.EDU
FLORIDA PHYSICIAN
FLORIDA PHYSICIAN MANDATORY CME REQUIREMENTS FOR LICENSE RENEWAL
Dear Colleagues,
The InforMed Florida Medical Licensure Program is designed to fulfill the mandatory CME requirements for physicians (MD) in Florida. Completion of the program satisfies requirements for two (2) hours on domestic violence, two (2) hours of prevention of medical errors, and two (2) hours of board-approved controlled substances. As a condition of biennial license renewal, physicians (MD) licensed by the state of Florida must complete at least two (2) hours on a board-approved controlled substances course if registered by the DEA and two (2) hours on medical errors. Licensees must also complete two (2) hours on domestic violence every third biennium.
To complete this program online, visit BOOK.CME.EDU , enter the book code MDFL0627 in the box then click GO .
Explore our course library to find content that meets your remaining state and national CME requirements.
Thank you for choosing lnforMed as your CME provider. We strive to create a high-quality, streamlined program for our colleagues. Please contact us with any questions, concerns, or suggestions.
Best Regards,
The lnforMed CME Team
We are a nationally accredited CME provider. For all board-related inquiries please contact:
Department of Health, Board of Medicine | 4052 Bald Cypress Way Bin C-03 | Tallahassee, FL 32399-3253 | (850) 245-4131
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BOOK CODE: MDFL0627
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i
What’s Inside
01
INTIMATE PARTNER VIOLENCE: COMPASSIONATE CARE, EFFECTIVE ASSESSMENT COURSE ONE | 2 CREDIT HOURS
SATISFIES THE DOMESTIC VIOLENCE REQUIREMENT The purpose of this course is to improve physician understanding of and competence in addressing intimate partner violence in their patient populations. It will provide information on evidence-based screening tools, and instructions for responding in compassionate and effective manners to their affected patients. Instructions for assisting patients in creating safety plans will be reviewed, and suggestions to identify resources helpful to victims of intimate partner violence. MEDICAL ERRORS AND THE UNITED STATES HEALTHCARE SYSTEM COURSE TWO | 2 CREDIT HOURS SATISFIES THE MEDICAL ERRORS REQUIREMENT The purpose of this course is to update physicians on the continuing impacts and challenges of medical errors for the healthcare system in the United States and to provide strategies to address root causes of these errors.
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STRATEGIES FOR APPROPRIATE OPIOID PRESCRIBING: THE FLORIDA REQUIREMENT COURSE THREE | 2 CREDIT HOURS
41
SATISFIES THE BOARD-APPROVED CONTROLLED SUBSTANCES/OPIOIDS REQUIREMENT Opioid analgesic medications can bring substantial relief to patients suffering from pain. However, the inappropriate use, abuse, and diversion of prescription drugs in America, particularly prescription opioids, has increased dramatically in recent years and has been identified as a national public health epidemic. A set of clinical tools, guidelines, and recommendations are now available for prescribers who treat pain patients with opioids. By implementing these tools, clinicians can effectively address issues related to the clinical management of opioid prescribing, opioid risk management, regulations surrounding the prescribing of opioids, and problematic opioid use by patients. In doing so, healthcare professionals are more likely to achieve a balance between the benefits and risks of opioid prescribing, optimize patient attainment of therapeutic goals, and avoid the risk to patient outcome, public health, and viability of their own practice imposed by deficits in knowledge.
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FINAL EXAMINATION ANSWER SHEET REQUIRED TO RECEIVE CREDIT
InforMed has the solution. Scan the QR code or go to https://uqr.to/deamate to get started. Effective June 27, 2023 , renewing DEA-registered practitioners must complete 8 hours of one-time training on the treatment and management of patients with opioid or substance use disorders. Get the training you need in a self-paced, convenient format with a course specifically designed for physicians to meet the Drug Enforcement Administration (DEA)’s new requirement under the Medication Access and Training Expansion (MATE) Act. Need to complete the DEA’s new requirement under the Medication Access and Training Expansion (MATE) Act?
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MOC/MIPS CREDIT INFORMATION
Table 1. MOC Recognition Statements Successful completion of certain enclosed CME activities, which includes participation in the evaluation component, enables the participant to earn up to the amounts and credit types shown in Table 2 below. It is the CME activity provider’s responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit. Board Programs Participants can earn MOC points equivalent to the amount of CME credits claimed for designated activities. InforMed currently reports to the following specialty boards: ABA, ABIM, ABS, ABPath and ABP. To be awarded MOC points, you must obtain a passing score, complete the corresponding activity evaluation, and provide required information necessary for reporting.
American Board of Anesthesiology’s redesigned Maintenance of Certification in Anesthesiology TM (MOCA®) program, known as MOCA 2.0®
ABA
ABIM
American Board of Internal Medicine’s Maintenance of Certification (MOC) program
ABS
American Board of Surgery’s Continuous Certification program
ABPath
American Board of Pathology’s Continuing Certification program
ABP
American Board of Pediatrics’ Maintenance of Certification (MOC) program
Table 2. Credits and Type Awarded
AMA PRA Category 1 Credits T M
Activity Title
ABA ABIM ABS
ABPath
ABP
Intimate Partner Violence: Compassionate Care, Effective Assessment
2 AMA PRA Category 1 Credits TM
2 Credits LL
2 Credits MK
2 Credits SA + AC
2 Credits LL
2 Credits LL
Medical Errors and the United States Healthcare System
2 AMA PRA Category 1 Credits TM
2 Credits LL
2 Credits MK
2 Credits SA + AC
2 Credits LL
2 Credits LL
Strategies for Appropriate Opioid Prescribing: The Florida Requirement
2 AMA PRA Category 1 Credits TM
2 Credits LL
2 Credits MK
2 Credits SA + AC
2 Credits LL
2 Credits LL+SA
Legend: LL = Lifelong Learning, MK = Medical Knowledge, SA = Self-Assessment, LL+SA = Lifelong Learning & Self-Assessment, AC = Accredited CME
DATA REPORTING: Federal, State, and Regulatory Agencies require disclosure of data reporting to all course participants. InforMed abides by each entity’s requirements for data reporting to attest compliance on your behalf. Reported data is governed by each entity’s confidentiality policy. To report compliance on your behalf, it’s mandatory that you must achieve a passing score and accurately fill out the learner information, activity and program evaluation, and the 90-day follow-up survey. Failure to accurately provide this information may result in your data being non-reportable and subject to actions by these entities.
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How to complete
Please read these instructions before proceeding. Read and study the enclosed courses and answer the final examination questions. To receive credit for your courses, you must provide your customer information and complete the mandatory evaluation. We offer two ways for you to complete. Choose an option below to receive credit and your certificate of completion.
ONLINE
FASTEST AND EASIEST!
• Go to BOOK.CME.EDU and enter code MDFL0627 in the book code box, then click GO.
Enter book code
• Proceed to your exam. If you already have an account, sign in with your username and password. If you do not have an account, you’ll be able to create one now. • Follow the online instructions to complete your final examination. Complete the purchase process to receive course credit and your certificate of completion. Please remember to complete the online evaluation.
MDFL0627
GO
IF YOU’RE ONLY COMPLETING CERTAIN COURSES IN THIS BOOK: • Go to BOOK.CME.EDU and enter the code that corresponds to the course below, then click GO. Each course will need to be completed individually, and the specified course price will apply.
Complete the answer sheet and evaluation found in the back of this book. Include your payment information and email address. Mail to: InforMed, PO Box 997432, Sacramento, CA 95899
BY MAIL
Mailed completions will be processed within 2 business days of receipt, and certificates emailed to the address provided. Submissions without a valid email address will be mailed to the postal address provided.
Program Options
Price
Option
Code
Credits
ENTIRE PROGRAM Intimate Partner Violence: Compassionate Care, Effective Assessment Medical Errors and the United States Healthcare System Strategies for Appropriate Opioid Prescribing: The Florida Requi rement
$50
MDFL0627 6 Credit Hours
$30
Intimate Partner Violence: Compassionate Care, Effective Assessment
MDFL02IP 2 Credit Hours
$30
Medical Errors and the United States Healthcare System
MDFL02ME 2 Credit Hours
$30
Strategies for Appropriate Opioid Prescribing: The Florida Requirement
MDFL02FL 2 Credit Hours
Note: Prices are subject to change
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________________________________ Intimate Partner Violence: Compassionate Care, Effective Assessment
MDFL02IP — 2 CREDITS
R elease D ate : 06/01/2023
E xpiration D ate : 04/30/2027
Intimate Partner Violence: Compassionate Care, Effective Assessment
In addition to receiving AMA PRA Category 1 Credit TM , physicians participating in Maintenance of Certification will receive the following points appropriate to their certifying board: 2 ABIM MOC Points, 2 ABS MOC Points, 2 ABA MOCA Points, 2 ABP MOC Points, 2 ABPath CC Points.
Faculty Dawn Demangone Yoon, MD Katie Blair, PharmD, RPh Stephen Braun, Medical Writer Faculty Disclosure
HOW TO RECEIVE CREDIT
• Read the enclosed course. • Complete the final examination questions at the end. A score of 70% is required. • Return your customer information/answer sheet, evaluation, and payment to InforMed by mail or complete online at BOOK.CME.EDU.
Contributing faculty, Dawn Demangone Yoon, MD; Katie lair; and Stephen Braun have disclosed no relevant financial relationship with any product manufacturer or service provider mentioned. Division Planner Michael Brooks , CME Director, InforMed Senior Director of Development and Academic Affairs Sarah Campbell Division Planners/Director Disclosure The division planners and director have disclosed no relevant financial relationship with any product manufacturer or service provider mentioned. Accreditations & Approvals In support of improving patient care, NetCE is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team. Designations of Credit NetCE designates this enduring material for a maximum of 2 AMA PRA Category 1 Credit(s) ™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Audience This course is designed for all physicians, physician assistants, nurse practitioners and other health care professionals who see patients abused in a current relationship, distressed by abuse in a prior relationship, or who suffer adult health effects that stem from witnessing IPV. Course Objective The purpose of this course is to improve physician understand- ing of and competence in addressing intimate partner violence in their patient populations. It will provide information on evidence-based screening tools, and instructions for respond- ing in compassionate and effective manners to their affected patients. Instructions for assisting patients in creating safety plans will be reviewed, and suggestions to identify resources helpful to victims of intimate partner violence. Learning Objectives 1. Describe the barriers experienced by patients and physicians that can prevent effective, compassionate care of potential survivors of IPV. 2. Describe two screening tools for identifying potential victims of IPV. 3. Identify three patient interviewing techniques of potential value in situations involving suspected IPV. 4. Describe the key elements of a safety plan for survivors of IPV.
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Intimate Partner Violence: Compassionate Care, Effective Assessment _ _______________________________
Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 2 MOC points in the American Board of Internal Medicine’s (ABIM) Maintenance of Certification (MOC) program. Participants will earn MOC points equivalent to the amount of CME credits claimed for the activity. It is the CME activity provider’s responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit. Completion of this course constitutes permission to share the completion data with ACCME. Successful completion of this CME activity, which includes participation in the evaluation component, enables the learner to earn credit toward the CME and Self-Assessment requirements of the American Board of Surgery’s Continuous Certification program. It is the CME activity provider’s responsibility to submit learner completion information to ACCME for the purpose of granting ABS credit. This activity has been approved for the American Board of Anesthesiology’s ® (ABA) requirements for Part II: Lifelong Learning and Self-Assessment of the American Board of Anesthesiology’s (ABA) redesigned Maintenance of Certification in Anesthesiology Program ® (MOCA ® ), known as MOCA 2.0 ® . Please consult the ABA website, www.theABA.org, for a list of all MOCA 2.0 requirements. Maintenance of Certification in Anesthesiology Program ® and MOCA ® are registered certification marks of the American Board of Anesthesiology ® . MOCA 2.0 ® is a trademark of the American Board of Anesthesiology ® . Successful completion of this CME activity, which includes participation in the activity with individual assessments of the participant and feedback to the participant, enables the participant to earn 2 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program. It is the CME activity provider’s responsibility to submit participant completion information to ACCME for the purpose of granting ABP MOC credit. This activity has been designated for 2 Lifelong Learning (Part II) credits for the American Board of Pathology Continuing Certification Program.
Successful completion of this CME activity, which includes participation in the evaluation component, earns credit toward the Lifelong Learning requirement(s) for the American Board of Ophthalmology’s Continuing Certification program. It is the CME activity provider’s responsibility to submit learner completion information to ACCME for the purpose of granting credit Through an agreement between the Accreditation Council for Continuing Medical Education and the Royal College of Physicians and Surgeons of Canada, medical practitioners participating in the Royal College MOC Program may record completion of accredited activities registered under the ACCME’s “CME in Support of MOC” program in Section 3 of the Royal College’s MOC Program. About the Sponsor The purpose of NetCE is to provide challenging curricula to assist healthcare professionals to raise their levels of expertise while fulfilling their continuing education requirements, thereby improving the quality of healthcare. Our contributing faculty members have taken care to ensure that the information and recommendations are accurate and compatible with the standards generally accepted at the time of publication. The publisher disclaims any liability, loss or damage incurred as a consequence, directly or indirectly, of the use and application of any of the contents. Participants are cautioned about the potential risk of using limited knowledge when integrating new techniques into practice. Disclosure Statement It is the policy of NetCE not to accept commercial support. Furthermore, commercial interests are prohibited from distributing or providing access to this activity to learners.
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________________________________ Intimate Partner Violence: Compassionate Care, Effective Assessment
Nearly all practicing healthcare professionals see patients who are either abused in a current relationship, are distressed by abuse in a prior relationship, or who suffer adult health effects that stem from witnessing IPV [3]. Yet, fewer than 9% of women are asked about IPV in the primary care setting [4]. In view of the prevalence and scope of intimate partner violence, it is prudent for clinicians to inquire routinely about a history of trauma and/or abuse across the lifespan, across genders, and across variations in sexual orientations. Extensive literature describes the “dose effect” of early child- hood trauma on later adverse health outcomes [5]. A history of trauma is a risk factor for current trauma. By addressing trauma and IPV, healthcare providers can address and, per- haps, prevent potentially severe physical and mental health consequences. A clinician intervention may simultaneously help a patient in an acute situation and uncover the root causes of health consequences due to IPV in that patient. As noted below, unaddressed or treatment non-responsive health conditions (e.g., delayed dental, neurological, gyne- cological, gastroenterological, or mental health conditions) may be due to underlying IPV [6; 7]. The prevention and treatment of IPV should thus be an integral component of routine medical practice. PREVALENCE OF IPV According to the most recent data from the National Intimate Partner and Sexual Violence Survey, conducted by the Centers for Disease Control and Prevention (CDC), 41% of women and 26% of men have experienced contact sexual violence, physical violence, and/or stalking by an intimate partner at some point during their lifetimes [6]. Over 53 million Ameri- can men and 61 million women have experienced psychological aggression by an intimate partner in their lifetime [6]. Other measures of the problem in the United States include: • Over half of female homicides in the United States were committed by a current or former male intimate partner [6]. • Women between the ages of 18–24 experience the highest rates of IPV [8]. • IPV is involved in 1 of every 4 women who attempt suicide [9]. • The average healthcare cost of each incident of IPV for women was $4273 [10]. • Overall costs related to IPV are estimated to exceed $9.3 billion each year, which includes medical and mental health care and lost productivity [10].
INTRODUCTION Intimate partner violence (IPV) is a serious public health issue in the United States, affecting approximately 36% of American women and 33% of American men in their lifetime.1 IPV is defined as deliberate coercive and harmful control by someone who is currently, or was previously, in an intimate relationship with another person, regardless of the duration or significance of the relationship. The term “intimate partner violence” is preferred to “domestic violence” because IPV is more inclu- sive—it doesn’t imply a shared residence between the two people [2]. IPV covers a spectrum of assaultive and coercive behaviors that can occur in any combination, in sporadic episodes or chronically, over a period of days, months, or even decades. They may include, but are not limited to: • Actual or threatened physical assault. • Sexual violence, including forced sexual intercourse and other forms of sexual coercion or exploitation. • Psychological/emotional abuse such as insults, belittling, constant humiliation, intimidation, threats of harm, or threats to take away children. • Controlling behaviors, including isolating a person from family and friends, monitoring movements, or restricting access to financial resources, employment, education or medical care. • Destruction of property or personal possessions • Sustained social isolation. • Spiritual abuse (i.e., coercion or manipulation justified by religious or spiritual beliefs). • Maltreatment of dependents including children, other family members, or animals/pets. Although most intimate partner violence is against women in heterosexual relationships, violence can be directed at any individual in any kind of relationship. Both survivors and perpetrators of abuse may self-identify as male, female, trans- gender, gender non-conforming, or as a member of another gender or sexual minority [2]. Because the bulk of violence occurs against women in heterosexual relationships, however, this guide focuses primarily on cis-heteronormative IPV. Clinicians may take an overly narrow view of IPV, seeing it only in terms of physical or sexual abuse in a relationship. IPV is not a situation where a couple is arguing or having a disagreement. It is a chronic and potentially life-threatening interpersonal situation. A broader view of IPV as a dysfunctional situation involving misuse of power and control is preferable [3]. How this dysfunction plays out – physically, emotionally, finan- cially, or through isolation or other forms of mistreatment, varies widely and may not conform to stereotypical ideas of “violence.” For example, perpetrators of IPV may harass a partner hundreds of times a day with phone calls, demand online access to passwords, or relentlessly stalk a partner or former partner in threatening or intimidating ways.
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Intimate Partner Violence: Compassionate Care, Effective Assessment _ _______________________________
Although IPV affects both women and men, and cuts across all age, racial, ethnic, religious, educational, and socioeconomic strata, research indicates a higher prevalence in certain groups [11]: • Women who are single, separated, or divorced. • Individuals who have recently sought a restraining/ vacate order. • Individuals who abuse alcohol or other drugs, or whose partners do. • Those with a partner: ‒ Who are excessively jealous or possessive. ‒ Experiencing unemployment or job instability. • Women who are pregnant and have been previously abused. • Low-income individuals, especially those in financial distress. • Adolescents and young adults. • Ethnic minorities. • Non-U.S.-born (immigrant) women. • Being gender non-conforming or a gender sexual minority. • Vulnerable groups such as those who are sex workers or disabled.
CONSEQUENCES OF IPV The physical and psychological consequences of intimate part- ner violence can be profound [12; 13]. Injuries from physical and sexual assault affect approximately 75% of female survivors and 48% of male survivors[6]. Female survivors have higher risks of sexually transmitted infections, including HIV, pelvic inflammatory disease, unintended pregnancy, and psycho- logical distress [7]. Long-term conditions associated with IPV include chronic pain, neurologic disorders, gastrointestinal disorders, migraine headaches, and other physical disabili- ties, as well as post-traumatic stress disorder, depression, and anxiety [7]. THEORETICAL MODELS Several models describe the dynamics of abusive relationships, two of which – The Duluth Power and Control Wheel, and Johnson’s Typology of Domestic Violence, are summarized here. The Duluth Power and Control Wheel In 1984, the Duluth Domestic Abuse Intervention Project developed a framework to describe the behavior of men who physically and emotionally abuse their female partners [14].
THE DULUTH POWER AND CONTROL WHEEL
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Derived from the experiences of women living with men who batter, the Power and Control Wheel was developed to graphi- cally represent the idea that acts of physical or sexual violence are part of a more general pattern of controlling behaviors, rather than isolated incidents of abuse, or as cyclical expres- sions of pent-up anger, frustration, or painful feelings. Johnson’s Typology of Domestic Violence Although the perpetrators of IPV are most often men, research that defines “violence” more broadly than just physical vio- lence, finds that men and women use “violent” tactics equally often in relationships [15]. Michael Johnson’s research divided couples into those who use what he terms “intimate terrorism,” in which an abuser (usually male) uses violence and power and control tactics that usually escalate. Their targets are the women most often seen in hospital emergency departments with severe injury, those likely to be abused during pregnancy, those most often forced into sex, and those with severe psycho- logical trauma. In contrast, “situational couple violence,” is a more frequent type of IPV and this term describes relationships in which both partners (heterosexual as well as same-sex) use aggressive tactics characterized by less severe and less control- ling tactics. Generally, these arise as a result of an argument in which one or both parties physically lash out. Situational couple violence is also less likely to involve sexual violence [15]. THE CYCLE OF VIOLENCE Many times abuse occurs in a predictable pattern or cycle. When the perpetrator shows affection to the survivor between abusive episodes, it can make it difficult for the survivor to leave the relationship. The cycle can involve the following phases: • Abuse – the perpetrator abuses their partner, asserting their power and control. • Guilt – the perpetrator feels guilty and fears that the abuse may lead to getting caught and facing consequences. • Excuses – the perpetrator rationalizes their abusive actions by blaming the partner and avoiding responsibility. • “Normal” behavior or “Honeymoon Phase” – the perpetrator attempts to regain control and keep the partner in the relationship, either by showing affection or acting as if the abuse never happened. • Fantasy and planning – the perpetrator starts to fantasize about abusing their partner again and plan the next episode of abuse. • Set-up – the perpetrator creates a situation where they can justify or blame their partner for the next abusive episode.
THE IPV CYCLE
Tension Building Phase
Honeymoon Phase
Abusive Incident
Source: [16]
MYTHS VS. REALITIES OF IPV Frustration is common among professionals who work with IPV survivors, and this frustration can be rooted in funda- mental misunderstandings about the way survivors of IPV behave. For example, contrary to a common perception that many women don’t leave abusive relationships, the majority do indeed leave or manage to make the violence end [17]. But leaving an abusive relationship is a process that may involve leaving and returning several times. Behavior change takes time and cycles of “relapse” and “remission” commonly seen in people trying to stop addictive behaviors such as smoking or drinking alcohol are also seen in people trying to escape abusive relationships. Patients need to move from a familiar unhealthy environment to a healthy unfamiliar one. Several studies have shown that formerly abused women are no more likely to go on to an abusive relationship than are other women in unhappy relationships [17]. Other studies have shown that survivors of IPV are best able to stay out of future abusive relationships and improve their health if economic and/or employment and/or housing opportunities are avail- able to enable financial independence [18]. It is important to remember that there is no “classic” type of victimized individual. Any person can be abused. Survivors come from all backgrounds, sexual orientations, genders, capabilities, education levels, and economic backgrounds. Universally, survivors desire lives free from abuse and are most likely to take steps toward this goal if provided with validation, support, opportunity, and health and economic security. The following statements reflect faulty beliefs or dysfunctional atti- tudes toward IPV, which are explained in the associated text. “She doesn’t look battered.” Often there are no obvious physical signs of abuse and/or the abuse may be psychological or emotional, rather than physical. Many elements that increase risk for lethality in IPV (i.e., threats of violence, jealousy) leave no signs.
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MDFL0627
Intimate Partner Violence: Compassionate Care, Effective Assessment _ _______________________________
“He beats her but she keeps going back!” As noted above, the victim and perpetrator may live in the cycle of violence where, after the abusive event, the perpe- trator feels guilty, apologies, brings flowers, and promises to never repeat the abuse. The victim hopes the perpetra- tor will embody their better sides moving forward. Other factors to consider are that the victim may be emotionally or financially dependent on the relationship, making it difficult to leave. Often victims have a family history of violence and so IPV relationships may be seen as normal. Lastly, women may internalize blame and responsibility. The message that IPV is the victim’s fault gets reinforced by repeated messages from the abuser and/or generalized societal, cultural, and media- transmitted messages that support social norms of submissiveness, inadequacy, or disempowerment. Women are often socialized to avoid conflict and promote harmony within the family at all costs. If they feel, for example, that the abuse prevents abuse of their children, then it may be perceived as not too high a price to pay for a peaceful household. ”Yes, he hit me but it’s my fault. I made him angry.” Viewing an instance of abuse as a result of one’s own actions is more empowering than if the person has no control. So justifying the abuser’s actions is one way to legitimize his actions. Additionally, with the cyclic nature of the IPV relationship, the terrorism and intimidation often build up prior to the event and usually become so intolerable that the abused does something to end the terrorism and initiate the abuse. “She presents with arm pain and odd injuries, but always denies IPV.” Reluctance on the part of a patient to disclose informa- tion about current or past abuse, even when specifically asked, may be due to embarrassment, shame, hope that the relationship can improve, or fear of retaliation by the perpetrator. External factors can also play a role: for example, the social pressure to avoid “losing” a partner or economic dependency. “We just fight. I hit him and he hits me.” Abuse occurs most often in a one-way direction. However, survivors may strike back in self-defense, which can then be used to excuse the behavior of the abuser. “He seems to be such a caring guy – there with her every visit and won’t leave the room.” Caring and controlling can manifest as similar, or even identical, behaviors that can be difficult or impossible to distinguish without long-term observation. “He’s losing his job and now, for the first time in 20 years, he hit me.” Abuse may evolve from non-violent to violent in tandem with stressors experienced by the perpetrator. Pregnancy, which can refocus a woman’s exclusive attention away from her partner, can also serve as a trigger.
OBSTACLES TO LEAVING AN ABUSIVE RELATIONSHIP
Survivors of IPV may face many barriers to leaving an abuser or to taking steps to prevent further abuse. The abuser may threaten to hurt or kill the victim, for example, or take away or hurt the children if the victim attempts to leave. Other potential obstacles include: Economic and logistical constraints Abusers often control the financial resources of the household as well as access to telephones, computers, passwords, car keys, and even medication and food, making it difficult for survivors to leave because they cannot (or believe they are unable to) independently support themselves and their children. They may track their partner electronically or call and text hundreds of times a day. Survivors may not know where to seek shelter or may be afraid to ask. Social isolation The abuser often prevents the victim from communicating with friends and family. Isolation leaves abused individuals psychologically dependent on the abuser as the sole source of social support and the only person who explains or interprets what is happening in the relationship. Feelings of failure Many survivors have been made to feel, by the abuser as well as by others, that they are failures and are responsible for hav- ing brought on the mistreatment. Survivors may also believe that their children need or deserve a two-parent family, even at the expense of their own safety. Social pressures, e.g., “not keeping your man” can also play a role. Promises of change A victim may believe the abuser’s expressions of remorse and subsequent promises that it will never happen again. He or she may feel that the abuser can change. Some survivors also feel it is somehow their responsibility to change or redeem their abusers. While some survivors may want the relationship to continue, most also clearly want the violence to stop. Religion Some victims may expect to endure sacrifices in life, and that suffering in this life will be rewarded in the next life, or that their current situation is due to acts committed in a past life. Others believe deeply in forgiveness and the power and grace it brings them to forgive the transgression of others. Some people view the breaking of marriage vows as sinful, or inter- pret religious texts as reinforcing control and domination. Religiously based support may not embrace personal safety and resources for abused women. Influences by religious leaders may reinforce a subordinate role for wives.
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________________________________ Intimate Partner Violence: Compassionate Care, Effective Assessment
Culture Some patients may come from cultures where leaving a mar- riage is shameful or virtually unheard of, regardless of how unsatisfying or even dangerous the relationship may be. If a survivor leaves, they would become even more socially isolated as a result. Prior lack of intervention All too often, survivors of abuse are either blamed for the violence or not taken seriously by family, healthcare profession- als, social service providers, and law enforcement authorities, leaving survivors feeling even more helpless and vulnerable.
not know about or understand the dynamics of violence and abuse, may not take the situation seriously, may not believe them, or may even blame the survivor for the abuse. As a result, survivors may exhibit a variety of problematic responses to the stress of ongoing or prior abuse (e.g., hypervigilance from PTSD, substance abuse), many of which make them “less than ideal” patients in a busy medical practice. When interviewed about their beliefs about partner abuse, and about their personal experiences of victimization, many primary care providers expressed fear of “opening Pandora’s Box” by broaching the topic of IPV with patients [20]. Associ- ated with this metaphor were five strong themes identified as distinct challenges. The first was “too close for comfort,” relat- ing to the finding that 14% of male physician respondents and 31% of female physician respondents in the study disclosed a previous personal experience of abuse. Other themes were fear of offending, powerlessness, loss of control, and “tyranny of the time schedule.” PATIENT BARRIERS TO DISCLOSURE Patients may hesitate to disclose current or past abuse to a healthcare provider for a variety of reasons [21]: 1. Fear of: ‒ The healthcare provider confronting the perpetrator. ‒ Retribution if the perpetrator learns of the disclosure. ‒ A breech in confidentiality if medical records are accessed by the perpetrator, child protective services, employers, police, or immigration authorities. 2. Shame and humiliation that abuse is taking place, or took place in the past, or not wanting to be perceived as a “victim.” 3. Belief that they deserved the abuse. 4. Protective feelings for the partner. 5. Inability to fully comprehend the situation. 6. Assumptions that: ‒ The doctor and staff are not knowledgeable or do not care about IPV because IPV may not be viewed as a medical issue. ‒ The doctor is too busy to spend time talking about IPV. ‒ The doctor can’t help with this problem or that it is inappropriate to discuss it. ‒ Same-sex abuse is not recognized, screened for, or treated. 7. Language, culture, and religion: ‒ Language barriers when communicating with providers, and fear of losing confidentiality with the use of an interpreter. ‒ Religious customs pushing survivors to stay silent about abuse.
IPV SCREENING AND ASSESSMENT
THE CLINICIAN’S ROLE The healthcare encounter can be invaluable for those in abu- sive relationships. Although survivors of IPV access medical services more frequently than non-abused individuals, most do not volunteer a history of abuse even to their primary care clinicians. Sensitive inquiry about IPV during an annual physi- cal examination, scheduled visit, or non-acute appointment, may reveal previously undisclosed abuse or can shed light on the underlying cause of an established chronic medical prob- lem. In addition, research has shown that most patients both welcome and appreciate inquiry about violence and abuse in the course of the medical visit when questions are asked in a manner that is sensitive, respectful, and confidential [19]. Abused individuals are more likely to disclose a history of abuse to their healthcare provider if the provider is perceived to be knowledgeable, nonjudgmental, respectful, and support- ive. Patients prefer that their clinicians take the initiative to inquire, as a matter of standard practice, about violence and abuse during the course of clinical encounters. The gender of the physician is not an important factor in the willingness of most patients to disclose or discuss abuse. The physician may need to ask on multiple occasions and over time, as a patient may need to feel they have a safe relationship to disclose their status. The physician can then help the patient develop a safety plan to prime the patient’s next leave attempt. It’s important to reiterate that a patient who remains in a dangerous or potentially dangerous relationship should not be labeled as a treatment failure or non-compliant. As noted ear- lier, choosing not to leave usually reflects the limited resources available to the survivor, or the patient’s reasonable assessment of available options and safety needs.
CLINICIAN BARRIERS TO EFFECTIVE, COMPASSIONATE CARE
Some healthcare providers find it challenging to address IPV, as well as other forms of violence and abuse. Survivors present frequently for medical care, and/or may come across as difficult patients. Many survivors believe that healthcare providers do
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SCREENING TOOLS Several instruments can be used to screen women for IPV. Those with the highest levels of sensitivity and specificity for identifying IPV, according to research by the USPSTF, are [1]: 1. Hurt, Insult, Threaten, Scream (HITS) : self- or clinician-administered 4-item questionnaire assessing the frequency of IPV. 2. Extended Hurt, Insult, Threaten, Scream (E-HITS) : includes an additional question on the frequency of sexual violence. 3. Humiliation, Afraid, Rape, Kick (HARK) : self- administered 4-item questionnaire assessing physical and emotional IPV in the past year. 4. Partner Violence Screen (PVS) : 3 item questionnaire assessing physical abuse and safety. 5. Woman Abuse Screen Tool (WAST) : 8 item questionnaire assessing emotional and physical IPV. The USPSTF found no valid, reliable screening tools to specifi- cally identify abuse of men or elderly or vulnerable adults in the primary care setting [1]. If your patient discloses that she or he has been abused, or if you suspect abuse without a disclosure, asking the following specific questions in a safe and confidential setting can help to determine the extent of abuse and the possible risk to your patient: • How were you hurt? • Has this happened before? • When did it first happen? • How badly have you been hurt in the past? • Have you needed to go to an emergency room for treatment? • Have you ever been threatened with a weapon, or has a weapon ever been used on you? • Have you ever tried to get a restraining order against a partner? • Have the children ever seen or heard you being threatened or hurt? • Have the children ever been threatened or hurt? • Do you know how you can get help for yourself if you were hurt or afraid? For adolescent patients, the following questions might be appropriate: • Have you begun to date? • Has your boyfriend/girlfriend ever threatened to hurt you? • Are you ever afraid of your boyfriend/girlfriend? • Have you ever had a pushing or shoving fight with a boyfriend/girlfriend? • Have you ever gotten hurt from a fight with a boyfriend/ girlfriend?
‒ Reluctance to “air dirty laundry” and cast a bad light on their community. 8. Immigration status being contingent on their current relationship, especially if they’re trafficked foreign nationals. 9. Sexual orientation and gender identity leading to fear of being “outed” or shamed. Additionally, perpetrators can control a patient’s ability to access healthcare. They may accompany the patient to health- care visits and even dominate the encounter and speak for the patient. Perpetrators can also affect a patient’s ability to adhere to medical instructions. They may confiscate or discard medications or medical devices as a way to control the patient. THE RADAR MODEL The United States Preventive Services Task Force (USPSTF) and the Affordable Care Act, along with many other organiza- tions, support routine screening for IPV and IPV counseling as part of preventive services. Research clearly shows that identifying survivors can promote their safety and improve health outcomes [22; 24]. The “RADAR” acronym developed by The Massachusetts Medical Society summarizes steps that healthcare providers can take to identify IPV and support victims: • R outinely screen: ask about IPV in the course of routine care. • A sk direct questions about violence such as, “At any time, has a partner or ex-partner hurt you, frightened you, isolated you, or made you feel unsafe?” Interview your patient in private whenever possible. • D ocument in the patient’s chart any findings related to suspected IPV. • A ssess for safety. Is the patient safe at home? Are firearms or other weapons kept in the house? Are children in danger? Is abuse or violence escalating? • R eview options with your patient, and make
appropriate community-based referrals (e.g., support groups, counseling, emergency shelter, legal advocacy).
A single question, asked routinely and non-judgmentally in the course of the social history, can significantly increase the detec- tion rate of IPV in office practice and can allow your patient to feel safe in disclosing a history of abuse. These sample ques- tions can be adapted as needed to individual practices; all have been shown to be accurate assessment questions for IPV [25]: • “At any time, has a partner hit, kicked, choked, threatened or otherwise hurt or frightened you?” • “Have you ever been in a relationship in which you felt unsafe or felt you had to ‘walk on eggshells’ to keep the peace?” • “Do you feel safe in your relationship?”
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________________________________ Intimate Partner Violence: Compassionate Care, Effective Assessment
Questions: 1. What potential obstacles exist that would prevent the clinician from providing effective, compassionate care to Marcy? 2. If it is possible to safely separate the husband and wife, what screening options can be considered to determine if Marcy has a history of IPV? Discussion Providing care to a patient in Marcy’s situation can be complex. Since Marcy presents with her husband, who appears to be controlling the situation, it may be difficult to have a discussion with Marcy without potentially confronting the perpetrator of violence. In addition, it is unclear if there are any language barriers to communicating with Marcy, and religious or cul- tural customs may also be barriers to disclosure of violence. It is possible that Marcy’s immigration status may also be contingent on her relationship with her husband, presenting another potential barrier. If Marcy can be safely questioned alone, a single question can help the provider determine if abuse is occurring. A question as simple as ‘do you feel safe in your relationship?’ can show the patient that the provider is compassionate, show the patient that the provider is alert to the situation in front of them, and open the line of communication between the patient and pro- vider. If time allows and communication barriers are absent, screening tools such as HITS, HARK, or WAST can be utilized. CLINICAL PRESENTATIONS An abusive act is rarely an isolated event. Violent behavior usu- ally recurs and often increases in frequency and severity over time. Although abused individuals may sustain life-threatening physical injuries, they often can suffer less obvious effects that are just as debilitating. In addition to physical trauma, survivors may present with a variety of other medical problems [27]. While some patients exhibit such “red flag” indicators of current or prior abuse, many others show no obvious signs or symptoms of medical or psychiatric distress, underscoring the importance of routine inquiry by clinicians or others on a healthcare team. In both ambulatory and emergency settings, survivors may present with a wide range of signs and symptoms that may include [2]: • Physical trauma, particularly lacerations,
• Have you begun to have sex? • Has anyone ever forced you to have sex when you didn’t want to? • Have you been able to talk to anyone you trust about what is going on? SAFETY ASSESSMENT If a patient has disclosed being in a threatening or violent relationship, the clinician can help the patient assess the level of risk, initiate a discussion of the need for a safety plan, and make referrals to appropriate services. The most important determinants in assessing risk are the patient’s level of fear and their own appraisal of both immedi- ate and future safety needs. Since patients may minimize the danger of their situations, however, the following questions have been found to provide a more objective assessment of IPV risk and whether it has been escalating and therefore likelihood for lethality [26]: • Has the physical violence increased in frequency or severity over the past 6 months? • Has you ever been threatened with a weapon or actually had a weapon used against you? • Do you believe your abuser is capable of killing you? • Have you ever been beaten while you were pregnant? • Is the person abusing you violently and constantly jealous of you? If any three of the above risk indicators are present, the patient should be referred immediately to a domestic violence commu- nity agency and, if necessary, to appropriate law enforcement authorities. Since lethality is augmented by the presence of a weapon, screening for the presence of a firearm, either one owned by the patient or the abuser, is extremely important. CASE STUDY 1 Marcy is a 22-year-old immigrant from the Philippines who is present- ing with an older man for an annual primary care exam. The man introduces himself to the provider as Marcy’s husband and insists on sitting close to the patient with his arm around her shoulders or hips. Marcy’s husband has a purse over his shoulder, and they both wear religious jewelry. Her husband states that Marcy moved from the Philippines with him when they got married last March, and that she does not have family in town. During routine interviewing, Marcy’s husband consistently answers for her, although Marcy’s English appears adequate for expressing herself. A physical exam reveals bruises on the woman’s breasts and abdomen; her husband states these injuries occurred because of a stumble down the stairs. Marcy averts her eyes during his explanation of the injuries and appears uncomfortable.
contusions, dislocations, fractures, head injury, or findings consistent with attempted strangulation (e.g., facial petechiae, laryngeal edema). Note that visible signs of strangulation may be more difficult to detect in darker-skinned patients than in those with fairer skin coloration.
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Intimate Partner Violence: Compassionate Care, Effective Assessment _ _______________________________
• Gynecological problems (genital lacerations and contusions, sexually transmitted infections, including HIV/AIDS, rapid repeat pregnancies). • Medical signs and symptoms such as headache, chest pain, abdominal pain, pelvic pain, fatigue, eating disorders, or functional gastrointestinal disorders. • Localized or generalized neurological findings such as altered mental status, seizures, motor or sensory deficits, and memory problems. • Behavioral/psychiatric signs such as anxiety, depression, panic, suicidal ideation or attempt, substance abuse • Social “red flags” such as frequent missed appointments, or non-adherence to prescriptions or medical instructions. • Partner “red flags” such as excessively attentive or jealous behavior on the part of a companion, a partner who insists on accompanying a patient during examinations, or a partner who speaks for the patient or displays dominant behaviors. • Delay between onset of injury and presentation for care. • New diagnoses of sexually transmitted infections may also result from sexual assault in an IPV relationship If any of these signs and symptoms are suspected to be the result of IPV, additional and more thorough questioning is warranted [5]. BEHAVIORAL SIGNS OF IPV Even in the absence of disclosure, patients may appear fright- ened, ashamed, embarrassed, defiant, or even overtly angry. Basic questions on the medical history may be answered in a manner that appears ambiguous or evasive. Other behavioral clues may include: • Partner accompanies the patient to clinical visit, insists on staying close, and speaks for the patient, answering questions or monitoring/controlling the patient’s responses. • The patient appears reluctant to speak independently or to disagree with partner. • Intense irrational jealousy or possessiveness expressed by partner or reported by patient. • Patient and/or partner deny, minimize, or divert questions about medical problems or injuries.
• Patient displays an exaggerated sense of personal responsibility for the relationship, including self blame for partner’s violence or for staying in the relationship. • Explanations that are inconsistent with observed illness or injury pattern. DOCUMENTING IPV Documentation in the medical record can provide valuable information if your patient seeks legal redress for abuse, as well as being the basis for optimal medical care. Even if the patient does not intend to take action now, the records may be needed later, for instance, in child custody proceedings. As vigorous criminal prosecution of intimate partner assault increases, accurate and legible medical records can often substitute for a physician’s personal testimony in court. Some electronic medical record systems (EMRs) have templates to facilitate IPV screening and/or sexual assault documenta- tion. Robust EMRs include prompts to remind providers to screen, and include links for inquiry and documentation formatting, lethality assessment questions, safety plan tips, and local resources. Additionally, for reasons of safety and confidentially, these systems have documentation and listing of IPV specifically excluded from clinical visit summaries, billing statements, and electronic health portals. One example is the Kaiser Permanente Systems Model approach [28; 29]. Many EMRs are currently used nationwide, resulting in wide variances in the use of prompted IPV screening. Whether using an EMR or not, clinicians should document findings carefully and non-judgmentally. Drawings or labeled photo- graphs may supplement a written description. It is important to describe the patient’s symptoms and signs accurately and to indicate “intimate partner violence” as a diagnosis or problem if appropriate. DOCUMENTATION DETAILS Records should be kept in a precise, professional manner, and should include the following:
For patients with acute physical injuries: a. Date and time of visit (if scheduled
appointment) or arrival (if in the emergency department). b. Contact information for anyone accompanying the survivor. c. Chief complaint and description of the event, using the patient’s own words in quotation marks whenever possible rather than the physician’s assessment. For example, “My husband hit me with his fist on _____ date at _____ time” is preferable to “Patient has been abused,” “Patient hit with a fist,” or “Patient alleges/claims she was hit.” d. Include the partner’s name in the record if possible.
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