We obtained 293 audiotapes that included a discussion of domestic violence. Patients were predominantly African American (83%) and single (63%), and 18% had less than a high school education. Only 77 of the 293 domestic violence discussions included patient disclosure of domestic violence to the provider. compares the demographic characteristics of enrolled patients with and without useable audiotapes and shows that audiotaped patients who did or did not disclose abuse to the provider were similar. shows demographic characteristics of providers. Patients were usually seen by more than 1 provider, which is typical at teaching hospitals.
Characteristics of Enrolled Patients
Characteristics of Participating Providers
Victims of domestic violence often seek care in emergency departments.
This study examines 293 audiotaped visits to 2 emergency departments during which providers screened adult women for domestic violence. Providers’ queries were often perfunctory. They usually did not include follow-up probing or offer open-ended opportunities to talk. Seventy-seven women disclosed domestic violence during the interviews; however, providers documented only 24 of the disclosures and referred only 19 women for counseling.
Audiotapes were made during a randomized trial that was testing computer screening for domestic violence. Providers knew they were being audiotaped.
Poor communication with victims of domestic violence is probably very common in emergency departments.
Patient disclosure of abuse usually referred to an intimate partner, although 9 patients (12%) reported intra-familial, acquaintance, or other types of domestic violence. Although most of the providers did not directly question patients about when the violence occurred, 27 (35%) patients indicated that the abuse was a current issue in their lives and 34 (44%) disclosed past experiences with abuse. Two patients reported both past and present abuse. In conversations in which the type of abuse was discernible, 12 (16%) patients disclosed emotional abuse and 26 (34%) disclosed physical abuse. Five patients (6%) mentioned both emotional and physical abuse. Only 24 of the 77 patients (32%) who disclosed abuse to the provider had any documentation of this discussion in their chart.
Context and Characteristics of Provider Inquiry
shows the context of the domestic violence discussions, which were almost always initiated by providers during the social history, as part of a checklist of risk factors. For example, a provider might ask, “Do you smoke? Do you drink alcohol often or use any street drugs? Do you have any problems with domestic violence?”
Context of Domestic Violence Discussion
shows examples of communication strategies that emergency department providers used to discuss domestic violence. Most often, provider inquiry was a variation of the question, “Are you a victim of domestic violence?” Screening questions were frequently (45%) asked in a perfunctory manner and were sometimes (10%) framed in the negative: “He’s never hit you?” Approximately one third of the time, providers probed (defined as asking ≥1 follow-up question after a patient’s initial response) for further information; 10% of the time, this included in-depth questioning or a detailed domestic violence history. Providers mentioned the computer screening 15% of the time.
Examples of Provider Communication Strategies
Communication Strategies and Disclosure of Abuse
shows provider communication strategies that appeared to be associated with patient disclosure. Patient disclosure of abuse was more likely to be found in audio-tapes in which the provider probed for domestic violence, created open-ended opportunities for discussion, and was generally responsive or expressed empathy when a patient mentioned a psychosocial issue (for example, “stress”). However, disclosures still occurred when the provider hesitated; used broken syntax, such as “um”; or laughed during the course of the domestic violence conversation. In the following excerpt, the provider elicited a traumatic abuse history from a young woman who presented with irregular menses just by mentioning the word “stress” and following up on a clue about a recent change:
Provider Inquiry Characteristics, by Patient Domestic Violence Disclosure Status
Provider: You can have irregular periods and just get plumbing problems. You can just be under a lot of stress.
Patient: That’s what I’m worried about. ‘Cause I haven’t had one since May.
Provider: Has it been worse at home since May?
Patient: (1-second pause) Yeah, it has. I had to leave home because my father— he was real terrible … He came in the room and he took the phone from me and then he threw it. So, at that, uh, point, I was just scared. My momma, she—she was shaking. And he also had a—a knife in his hand. . . . he was trying to stab me.
The opportunity to have a meaningful conversation about abuse was often diminished by provider factors, such as screening the patient in the presence of a third party, failure to acknowledge disclosure of abuse, lack of assessment of safety or level of risk, and failure to link the patient with available resources.
In one encounter, the provider asked during the examination, “Any problems at all with domestic violence? I have to give him the evil eye when I ask that question.” The patient laughed, and the provider then addressed her male partner and asked. “Now, is she givin’ you any trouble?” He responded, “Yep.” This approach minimizes the seriousness of domestic violence and fails to provide the confidentiality needed; patients are unlikely to disclose domestic violence in the presence of an abusive partner. In a similar encounter, the male partner volunteers, “I can leave if you like,” providing evidence that patients and their family members take questions about abuse seriously and expect the topic to be asked about in private.
A few provider responses to patient disclosure of abuse were insensitive. In this example, the provider regards the domestic violence disclosure as something that should be addressed by study personnel, even when specifically asked by the patient about help for abuse:
Patient: It says you know where someone could get help for physical or sexual abuse. Do you have information on how I …
Provider: The lady who gave you this paper will give you this … to the triage area, and she’s gonna give you this. (4-second pause) Okay?
This patient described an assault by someone other than an intimate partner:
Patient: Hit me in the face … that was like … almost a year ago.
Provider: All right. But that’s not really domestic.
Patient: No. Right— Right— N-Not— I don’t—.
Provider: Okay, so that’s (…). Okay. (1-second pause) Any coughing or shortness of breath?
In this excerpt, the provider inquired about stress but changed the topic when the patient disclosed conflict in her relationship, returning the conversation to the biomedical concerns:
Patient: Uh, me and my boyfriend, we fight sometimes. (2-second pause)
Provider: Well, that’s some degree of stress.
Patient: (Laughs) Yeah. (4-second pause).
Provider: Okay. Well, I think this is the problem. Okay. Let’s— Let’s do this … We’ll do the EKG. Okay?
Provider: And we can try to give you some uh, some Mylanta (1-second pause). Maybe you—you might have reflux. Sometimes people with high anxiety, they have high acidity, and this will (…).
In the following example, the provider paused awkwardly for 19 seconds and then abruptly changed the topic of conversation to an unrelated medical issue. This interaction is typical of a missed empathic opportunity (12
Provider: Have you ever been threatened or hurt by (…) or someone close to you?
Patient: Yeah. (19-second pause)
Provider: Are you allergic to any medicine?
Other providers were more responsive but did not know how to assess safety or match resources appropriate to the level of risk:
Provider: Okay. (1-second pause) Um. (1-second pause) Do you have (1-second pause) a plan to get out if it gets too bad or … ?
Patient: (Overlap) No. I don’t know how to get out. I’m tryin’—I’m tryin’ to go somewhere and get, you know– I don’t know where to go. But they—they said they got the places where they can put (…). (1-second pause)
Provider: I can give you some information. Would that help?
Patient: (Overlap) Okay. I appreciate it. Yeah.
Provider: Here’s some, um, information for ya. Okay.
A number, um, for a domestic violence hotline. Okay? (1-second pause) This has some—
Patient: Don’t they need to go through gettin’ the reports and all that for the domestic violence? You know?
Provider: You know, I don’t know.
Helpful Provider Responses
We also found examples of positive provider responses to disclosure of abuse. These included allowing the patient to talk about their experiences; checking to be sure the patient was not in any current danger (safety checks); counseling; mentioning available law enforcement and legal recourses, bringing in a social worker, and showing empathy and concern; voicing helpful opinions; and reinforcing the importance of following up with referrals. The following excerpt is exemplary. The provider is generally responsive, listens, validates the patient, and encourages her to get counseling in a way that empowers her to make changes:
Patient: … (…). And I’m really tired. I’m really tired of him taking advantage of me. You know?
Provider: Mm hmm.
Patient: … I might have a little weight on me.
Provider: (Overlap) (…) don’t ever think that you’re not a pretty lady. You know what? We have people here you can talk to. And you may find that just talking to somebody a few times could get you over this.
Provider: You know, you may not need 6 months of therapy. You may just need somebody to tell you what direction to go.
Provider: ’Cause there’s a lot of self-help out there as well. And you’re smart enough to be able to sort it out.
This provider offers a private opportunity for the patient to disclose and leaves the door open for future support:
Provider: [To male third party]: Can you step out for 1 second and just let us talk alone just for 1 second?
Male partner: Sure. Okay. (Laugh)
Provider: I noticed you filled out this questionnaire out in the waiting area. And, uh, the only thing I just wanted to discuss with you is, uh (…) partner-to-partner (…). Does he ever—Has anybody ever threatened you, or do you ever feel threatened?
[long patient explanation edited out]
Patient: Yeah. We’d been talking about (…) controlling thing. But he can’t—Once he’s mad, he can’t just (…). It’s not physical.
Provider: No physical violence.
Patient: (Overlap) (…). No.
Provider: If you need any help, we’re here for you.
Several emergency care providers offered assistance to patients who disclosed past or current abuse; this assistance mainly took the form of discussing safety. In 59% of the 77 domestic violence disclosures, the provider performed a safety check. In 38% of disclosures, the provider expressed empathy or concern for the patient and their circumstances. However, a specific domestic violence referral was discussed in only 19 of 77 (25%) domestic violence disclosures by patients, only 12 (16%) providers mentioned involving the police or legal authorities, and only 3 (4%) patients disclosing domestic violence were seen by a social worker. Consistent with the general failure to document abuse, no provider mentioned that the medical records might be of use, should the patient need to go to court.