If It Hurts, It's Not Love - The Diagnosis Doctors Miss

The medical community recently mourned the loss of Dr. Tamara O’Neal, an Emergency Medicine physician shot and killed by an ex-partner while she was working at Mercy Hospital in Chicago. Her death came on the heels of an annual analysis of the Federal Bureau of Investigation (FBI) Supplemental Homicide Reports which showed that in 2016, the most recent national dataset available, 63% of female homicide victims were killed by a current or previous intimate partner.1 Since reaching its nadir in 2014, the national incidence of intimate partner violence (IPV) has increased the last two years — up 11% since 2014.1 In September 2018, the United States Preventive Services Task Force released guidelines that recommend screening all women of child-bearing age for IPV.2 Despite growing recognition of the health risks of IPV and the healthcare workforce’s responsibility to care for survivors, most health providers fail to ask their patients about IPV.3 In addition, IPV is rarely prioritized in provider performance standards and reimbursement models.

As a research consultant on violence against women for the World Health Organization (WHO), I’ve worked with health professionals, medical associations, and governments around the world on the health-sector response to IPV. I’ve noticed stark differences in how IPV is viewed compared to other pressing health issues.

Take breast cancer, a disease that convinces the burliest NFL players to don pink shoes on national television, and high school boys to purchase ‘I love boobies’ wrist bands in bulk. In 2017, the NIH allocated $656 million to breast cancer research compared to $30 million spent on violence against women, despite the fact that IPV affects women more than twice as often as breast cancer.4 A cancer diagnosis is a tragedy that deserves widespread attention, but why doesn’t equivalent support exist to combat IPV? The answer has little to do with relative public health impact and a lot to do with priorities.

Today’s underpreparation of the healthcare workforce and lack of system-based health responses is rooted in historically prejudiced views of IPV as a ‘private matter’ or ‘social issue.’ Although the WHO definition of health has existed since 1948 as the physical, mental, and social well-being and “not merely the absence of disease or infirmity,” a biomedical model of healthcare and medical training has persisted. However, there is growing effort that it be replaced with a biopsychosocial framework.

Health providers are uniquely situated to respond to IPV. Women who have experienced IPV use extensive healthcare resources and identify health providers as the professionals they trust for disclosing abuse.3,5 Importantly, IPV is an experience, not a diagnosis, and reactions to traumatic events like IPV may result in a several adverse health issues. Like many complex health issues, IPV has no guaranteed cure, but recognizing the underlying etiology of the adverse health issue (e.g. IPV) is a vital foundational event. There are simple steps providers can take. Health professionals should ask women of child-bearing age about partner violence and provide initial support in a sensitive and confidential manner, making referrals to legal and other support services as necessary (see Table 1).6 Many validated tools exist (see footnote) and are freely accessible online. In addition, providers can offer additional ongoing support through trauma-informed healthcare, motivational interviewing, and safety planning.

Clinician inquiry is only one part of creating a robust health system based IPV response. Issues like performance standards, reimbursement models, and access to trauma-informed health issues and other specialized services are also lagging, and often drive the process of clinical care. These accompanying issues are often beyond an individual provider’s control, but healthcare organizations and entities like the United States Centers for Medicare and Medicaid can help facilitate needed changes. In fact, if reimbursement models can more closely align with what providers see in practice, IPV might rise to the status it rightly deserves. As such, healthcare organizations and insurance companies must take more of a leadership role in facilitating the needed complete transformation of healthcare so that IPV, other trauma-related experiences and related health issues, are given the appropriate prioritization and reimbursement. 

The death of Dr. O’Neal and emerging global movements like #MeToo remind us of the devastating consequences of intimate partner violence. Despite its enormous health and economic impact, the American health system is failing to address the unique clinical needs of IPV survivors. Through increased provider training, IPV prioritization in performance standards and reimbursement models, implementation of institutional protocols for IPV, and improved access to trauma-informed care, entire healthcare workforces can be equipped to respond sensitively and effectively to survivors. A doctor’s office may be the only opportunity to intervene and make a life-altering difference.

Please note: some validated screening tools are available FREE and online.

HARK – https://jwat.ch/2RvJerz;

HITS – https://jwat.ch/2SIz9cz; PVS – https://jwat.ch/2JzJJOy

WAST – https://jwat.ch/2zpJTmW 

LIVES: First-line support for intimate partner violence. Adapted from the WHO clinical handbook. 6

Steps Followed By Examples

Listen without judgement

Make eye contact. Minimize distractions.

Inquire about concerns

What do you need?

What worries you the most?

Validate experience

This is not your fault.

Everyone deserves to feel safe.

Enhance safety

Has this person ever threatened to kill you?

If things escalate again, what will you do?

Support, e.g. shelter, legal, police

Would you find it helpful to talk to another professional about this?

Do you need a place to stay?

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References

1. When men murder women: An analysis of 2016 homicide data. Washington (DC): Violence Policy Center; 2018 Sept. Available from: http://vpc.org/studies/wmmw2018.pdf

2. Screening for Intimate Partner Violence, Elder Abuse, and Abuse of Vulnerable Adults. JAMA. 2018;320(16):1678-1687.

3. Feder GS, Hutson M, Ramsay J, Taket AR. Women exposed to intimate partner violence: expectations and experiences when they encounter health care professionals: a meta-analysis of qualitative studies. Arch Intern Med 2006;166(1):22-37.

4. Estimates of funding for various research, condition, and disease categories. Bethesda (MD): National Institutes of Health; 2018 May. Available from: http://report.nih.gov/categorical_spending.aspx

5. Bonomi AE, Anderson ML, Rivara FP, Thompson RS. Health care utilization and costs associated with physical and nonphysical-only intimate partner violence. Health Serv Res. 2009;44(3):1052-67.

6. Health care for women subjected to intimate partner violence or sexual violence: A clinical handbook. Geneva: World Health Organization; 2014 Nov. Available from: http://apps.who.int/iris/bitstream/handle/10665/136101/WHO_RHR_14.26_eng.pdf;jsessionid=1600BFA75E0F506946D497CD0720D131?sequence=1