Importance of Screening for Abuse in Clinical Settings
Whether or not patients in physicians' offices should be screened for abuse is an issue under debate in the literature. Ramsay et al.2 reviewed 20 articles on screening for abuse in clinical settings and found that although a majority of women respondents felt it was acceptable, a majority of physicians and emergency department nurses were not in favor of it. Other than increased referral to outside agencies, the authors claim that little evidence exists for changes in important outcomes such as decreased exposure to violence. Despite their overall judgment of a poor quality and inadequate body of literature, the authors leap to the conclusion that, although domestic violence is a common problem with major health consequences for women, implementation of screening programs in healthcare settings cannot be justified.
Reaction to this proclamation was quick and mostly negative. In the next issue of BMJ, the editors reported receiving 28 letters responding to Ramsay et al., with over half agreeing that screening would require a culture shift to zero tolerance of domestic violence, as we have seen for child abuse.52-53 There was also general agreement that screening is a health professional's responsibility. Screening by a health professional "may be the first link in activating the chain of survival" (page 1419).52 One commentator took the stand that a physician's duty to report a crime should take precedence over the duty to maintain patient confidentiality.54 New regulations under the Health Information Portability and Accountability Act55 will undoubtedly intensify this debate.
Medical organizations have certainly rallied in support of screening for domestic violence by health professionals.
- The American College of Obstetricians and Gynecologists and the International Federation of Gynecology and Obstetrics have issued statements encouraging their members to initiate screening in their practice and to take action to stop domestic violence.56
- The International Journal of Gynecology and Obstetrics issued a supplement in September, 2002, dedicated to the problem of domestic violence, including proceedings of the International Conference on the Role of Health Professionals in Addressing Violence Against Women that was held on Oct. 15, 2000, in Naples, Italy.56
- American Medical Association57
- the Institute of Medicine58
- American Association of Family Practitioners
- Family Violence Prevention Fund
- Physicians for a Violence-free Society59
- Joint Commission on Accreditation of Healthcare Organizations60
Even the Joint Commission on Accreditation of Healthcare Organizations60 requires written policies to improve identification and assessment of domestic violence victims, provider education, patient consent, and documentation of abuse. The standard of care for all medical, mental health, legal, and social work practitioners requires universal screening, basic safety planning, and appropriate referral to community resources.61
Other reasons for screening patients for domestic violence, besides the ethical obligation to report a crime and liability for failure to report, are related to treatment outcomes. Lack of compliance with medical recommendations and unresponsiveness to treatment may not be the result of the woman's actions or attitudes. Special interviewing techniques are required to elicit relevant information from patients.62
Based on excerpts from Nosek, M.A., Hughes, R.B., Taylor, H.B., Howland, C.A. (2004) Violence against women with disabilities: The role of physicians in filling the treatment gap. In: S.L. Welner and F. Haseltine (Eds.) Welner's Guide to Care of Women with Disabilities.(pp. 333-345) Lippincott, Williams & Wilkins, Philadelphia.
2. Ramsay J, Richardson J, Carter YH, Davidson LL, & Feder G. Should health professionals screen women for domestic violence? Systematic review. BMJ, 2002 Aug 10;325(7359):314.
52. Twisselmunn, B. Summary of responses [toRamsay et al]. BMJ. 2002 Dec 14;325(7377):1419.
53. Nurse, J. Culture shift is needed. BMJ. 2002 Dec 14;325(7377):1417.
54. Davies, P. Doctor's duty of confidentiality may not be in patient's or community's interest. BMJ. 2002 Dec 14;325(7377):1418.
55. Health Insurance Portability and Accountability Act of 1996 Public Law 104-191, Aug. 21, 1996; http://aspe.hhs.gov/admnsimp/pl104191.htm.
56. Jones RF 3rd, Horan DL. The American College of Obstetricians and Gynecologists: responding to violence against women. Int J Gynaecol Obstet 2002, Sep;78 Suppl 1:S75-7.
57. American Medical Association. Diagnostic and Treatment Guidelines on Domestic Violence. Chicago, IL: American Medical Association; 1992.
58. Cohn F, Salmon M, Stobo J, eds. Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence. Washington, DC: Institute of Medicine, 2002.
59. Bauer ST, Shadigian EM. Screening for violence makes a difference and saves lives. BMJ. 2002 Dec 14;325(7377):1417.
60. Joint Commission on Accreditation of Healthcare Organizations (JCAHO). Comprehensive Accreditation Manual for Hospitals, Update 3. 1997. p. PE-10-PE-34.
61. Buel SM. Treatment guidelines for healthcare providers' interventions with domestic violence victims: experience from the USA. Int J Gynaecol Obstet 2002 Sep;78 Suppl 1:S39-44.
62. Varjavand N, Cohen DG, & Novack DH. (2002) An assessment of residents' abilities to detect and manage domestic violence. J Gen Intern Med, 2002 Jun; 17(6):465-8.