“Do you smoke? How often do you exercise? Do you feel unsafe in your relationship?”
Providers ask patients routine questions like these to assess their risk of disease or, in the case of the third inquiry, their physical safety. But, for some patients, asking about their experience with intimate partner violence in this manner can feel more like a checklist item than something that merits a longer conversation, according to speakers at BWH’s annual event honoring V-Day on Feb. 9.
The event, which included a panel discussion and a role-playing session between a mock provider and patient, explored challenges and opportunities clinicians face in caring for patients who have experienced intimate partner violence. The discussion also highlighted services and resources for BWH clinicians such as Passageway, which can provide consultations, in-service training and provider support in caring for patients who have experienced abuse.
Organized by the BWH V-Day Planning Committee, the event was among the hundreds that took place around the world that day to honor V-Day, a movement aimed at raising awareness about violence against women and girls.
“Intimate partner violence is ubiquitous, and there’s a role for all of us to increase our sensitivity to and understanding of these experiences,” said Jeffrey Katz, MD, MSc, who moderated the panel and has helped lead efforts to organize the annual event. “Those of us who work in a clinical environment have the special privilege and responsibility of identifying and providing appropriate care for these patients.”
Speakers advised clinicians to practice trauma-informed care – which recognizes the multiple symptoms and effects of trauma, incorporates that knowledge into practice and procedures, and avoids actions that may retraumatize the patient – when they suspect or learn a patient has experienced intimate partner violence.
“We’re often glancing at the computer as we ask a patient whether they have been hit, kicked or punched or experienced forced sex. As a result, the patient may not feel a connection,” said Annie Lewis-O’Connor, PhD, NP, founder and director of BWH’s Coordinated Approach to Recovery and Empowerment (C.A.R.E.) Clinic. “But if you sit beside them and say, ‘I ask all my patients about their relationships, and I have a few questions about your relationship,’ it becomes a conversation.”
Meeting Patients Where They Are
Patients frequently disclose abuse in vague or incomplete ways, and it’s important not to press for details that might be triggering, speakers noted. Allowing patients to say as much – or as little – as they’d like builds trust, said Jackie Savage-Borne, MSW, LICSW, hospital program manager for Passageway. When a patient discloses abuse, thanking the patient for sharing their story and acknowledging their courage is also vital, said Hanni Stoklosa, MD, MPH, a physician in the Department of Emergency Medicine and executive director of HEAL Trafficking.
If a physical exam is needed, it is helpful to first explain what you would like to examine and why, added Nomi Levy-Carrick, MD, MPhil, of the Division of Medical Psychiatry.
During the role-play portion of the event, Passageway staff acted out examples of how a provider-patient interaction could unfold based on the clinician’s tone and approach. Savage-Borne played the part of a primary care physician speaking with a patient, portrayed by Jessica Loftus, MSW, LICSW, community program manager at Passageway.
In the first scenario, Savage-Borne depicted a common way providers broach the topic of intimate partner violence: “There are some questions I need to ask you, and I’m sorry to do this, but we’re supposed to ask these. Are you safe in your relationship? Is anyone hurting you? Things are good in your relationship?” In the end, the patient disclosed few details about her abuser. She was handed a pamphlet with a list of resources, which she left behind after the encounter ended.
During the second round, Savage-Borne demonstrated a trauma-informed approach: “Part of my ability to care for my patients is to ask some questions about safety in relationships. I ask all my patients these questions because so many people experience control and fear in their relationships. Would you feel comfortable telling me a little more about your relationship?” The patient revealed details indicating she was at risk for domestic violence. The provider asked if it was OK to page a Passageway advocate to discuss available resources; the patient agreed.
“We should always offer options. If the patient declines to see an advocate, you can provide a brochure or put a note in their health record,” said Mardi Chadwick Balcom, JD, director of Violence Intervention and Prevention. “It might take a few times before someone is willing to say yes, so it’s important to revisit in intentional, caring ways.”