________________________________ Intimate Partner Violence: Compassionate Care, Effective Assessment
Questions 1. What are some examples of communication strategies you should avoid when collecting more information? 2. What IPV-specific documentation should you include in your progress note for this encounter? Discussion In the interview with Jennifer, it is important to refrain from asking questions in a manner that might frighten or intimidate your patient, increase the sense of humiliation and shame about the violence, or be interpreted as blaming the survivor for the situation. Since discussing IPV can be very difficult and can leave patients feeling vulnerable, Jennifer may feel more comfortable having a discussion while fully clothed. Discussions about IPV should be avoided in the presence of children who can comprehend the situation, so it may be best to have Jennifer’s daughter leave the room or have Jennifer call the clinic later to discuss when she is alone. In addition, Jen- nifer should be assured that patient confidentiality will not be broken by disclosing any information or discussing concerns with her husband. When documenting the encounter in a progress note, it is important to use Jennifer’s words in quotations whenever possible to detail her description of her relationship safety. If any injuries are found during the physical exam, they should be described in detail, as well as an opinion on whether the injuries were adequately explained. Photographs or additional imaging studies may be included if appropriate. USING COMMUNITY RESOURCES/REFERRALS Clinicians who may encounter survivors of IPV should explore all local support resources and keep an updated patient hand- out with their contact information. Establishing personal relationships with key personnel in community support organizations can not only improve a clinician’s understand- ing of the many social and legal dimensions of IPV, but it can facilitate referrals. Many community IPV programs include a confidential emer- gency shelter or safe house program. Some can provide tem- porary transitional housing or safe-at-home services. Although emergency shelter is usually a last resort for those who are in acute danger, the shelter offers a safe haven from violence and can also provide the survivor with information about rights and options as well as vital emotional and logistical support. In many programs, specialized services are available for children who have been traumatized by witnessing abuse. In shelter programs, women have a chance to meet other women who have sought shelter, which can help women break out of the profound social isolation that is so often a component of abuse.
Most patients with a history of being abused, although per- haps dealing with difficult medical and emotional sequelae, are not in acute danger at the time of the visit. If the patient discloses victimization, the physician should conduct a brief safety assessment (see above), offer information and hotline numbers, convey concern and support for the patient, and arrange a follow-up to discuss the abuse and possible options in greater detail. Only rarely will the clinician be confronted with a patient in extreme danger or who has acute needs. In this situation, as in the case of any medical emergency, urgent action is needed. While there are various guidelines outlining what patients may need from the health care system after experiencing IPV, there is little guidance on how to actually integrate and imple- ment these practices within clinics. Treating IPV in a chronic care model and creating a team within clinical settings helps improve screening rates and provides interventions in a timely manner. The following six-point model summarizes how to create a sustainable system-level program [32]: • Step 1 - Identify an IPV Champion (someone with on-site IPV expertise). • Step 2 - Train all staff and define roles when responding to IPV (i.e., saturation training). • Step 3 - Create clinic-based policies and procedures. These will outline staff training efforts, use of EMR documentation, identification of “at risk” patients longitudinally, create follow-up plans, and streamline referral to internal and local community programs. • Step 4 - Use the IPV Champion to build bridges and collaboration with local advocacy agencies and IPV experts. This ultimately allows for effective communication and “warm” referrals. • Step 5 - Evaluate all clinical efforts regarding screening and periodically re-evaluate for dissemination to the clinical team. • Step 6 - Provide general information to patients outlining healthy relationships as well as healthy conflict resolution strategies (e.g., pamphlets, posters, signage). CASE STUDY 2 Jennifer is a 32-year-old married woman who presents for an annual exam with her 6-year-old daughter. She works full-time as an ophthal- mologist and appears clean, professional, and poised. Jennifer and her husband have been your patients for 5 years, and her overall health is good, with only minor health concerns in her past medical history. Jennifer’s appointment is in the afternoon, and you are running late after a series of delays with previous patients. You review her vitals and start to perform a physical exam. You glance at the clock and see you are already out of time for this appointment. To save time, while you are performing a breast exam, you ask Jennifer “Do you feel safe in your relationship?” To your surprise, she suddenly tears up and averts her eyes. She does not immediately respond to the question.
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