Intimate partner violence (IPV) is a pattern of controlling behaviors against a current or former intimate partner. The motive is control or intimidation of the partner or harm to the partner. Over 15 years ago, the American Medical Association (AMA) first recommended universal screening for IPV. Declaring the epidemic of family violence as "sufficiently prevalent to justify routine screening of all women patients," the AMA officially endorsed active physician involvement [1
]. As inquiry for IPV became more routine, identification rates increased to as high as 30% among some populations [3
]. IPV is present across all demographic groups including healthcare providers [4
Despite the AMA's Campaign Against Family Violence, many physicians still do not routinely inquire about IPV [5
]. Physicians attribute this to a lack of institutional support [6
] and competing demands to assess and treat patients for a myriad of acute and chronic care issues in 15-minute visits. Many physicians report feeling uncomfortable with inquiry about IPV [6
], and powerless to help these patients in any meaningful way [6
]. Physicians often lack training and information about community resources, or are unaware of the guidelines set forth by the American Medical Association and other medical organizations recommending identification of IPV [7
]. While models of IPV curricula exist [14
], there is little published data on how to train community physicians.
Concomitantly, many patients in physician practices never disclose IPV for fear of retaliation by their partners [6
] or fear that the physician may notify authorities, creating an increased risk for harm [6
]. Patients who do disclose IPV often choose not to follow up on referrals, reinforcing the physician's sense of powerlessness and frustration [6
]. Cultural differences leave patients skeptical about their physician's ability to understand gender roles and expectations of their ethnic groups [6
]. Some patients fear that their physician is too busy to help. Often patients do not understand that IPV is classified as a public health issue which falls within the health care provider's purview [8
These barriers to identification and management of IPV and the absence of ways of training community physicians in IPV management prompted a small pilot study of academic detailing using seven brief, focused, one-to-one detailing sessions. Academic detailing (also referred to as educational outreach) is among the most effective methods for changing provider behavior. It is defined as "use of a trained person from outside the practice setting who meets with healthcare professionals in their practice settings to provide information with the intent of changing their performance" [17
A key principle of academic detailing is preliminary surveillance of health care professionals to assess barriers to appropriate practice. A baseline assessment of clinician knowledge and motivation surrounding the clinical practice is conducted. An intervention is designed with clear educational and behavioral objectives, including efforts to address the identified barriers, and simple messages are developed for delivery by a credible person. The clinician is engaged to actively participate, while the detailer repeats key messages, and reinforces practice change through follow-up visits [18
]. Originally, academic detailing was described as a multi-component intervention. There are conflicting reports on the superiority of multi-component compared with single component interventions [19
]. Academic detailing initially included feedback on existing practice and over time changed into a number of different variations that also appear to vary in effectiveness [18
Typically, a detailer (who is often a pharmacist or nurse) schedules a 15-30 minute visit with a physician to review a particular topic. Often, the detailer begins by seeking to understand the physician's practice (what is your usual approach to X?) and his or her attitudes (what is your thinking about using X or Y?). Then the detailer proceeds to provide information (are you familiar with this recent evidence review or report?) and assess the physician reaction (what are your thoughts about it?). The detailer often concludes their session with an offer to provide written materials (would you like to see a copy of the report or the assessment tools?). A systematic review of the literature [17
] confirms the benefit of academic detailing. While academic detailing has been used widely across the world (North America, the United Kingdom, Europe, Australia, Indonesia and Thailand), it has been used primarily to change physician prescribing behavior. Academic detailing has much less often been used in an attempt to change complex physician behavior.
In most studies, the credentials of the detailer are noted, but the potential for influence is not described. Studies based on social marketing theory describe the detailer as someone thought to be credible in the opinion of the health care professionals. Few trials compare visits delivered by a peer versus a non-peer. To our knowledge, academic detailing has not been previously used to improve physician management skills with IPV. We previously reported that this pilot intervention improved physician behavior. Prior to the intervention, 36/150 (24%) of sample patients reported having been previously asked about IPV and 24/150 (16%) reported being asked in a written format. After the intervention, 100/149 (67%) and 41/108(28%) reported being asked verbally or in writing, respectively about IPV [25
]. Physicians also reported that their practice patterns changed over the course of the study. They reported more frequently inquiring about and documenting IPV after completing several teaching modules. Of note, physician post-intervention scores on a printed IPV knowledge test did not change appreciably [25
]. Despite the physicians' pre-existing base of IPV knowledge, they had not been inquiring about or documenting IPV in any meaningful way prior to the intervention. The study physicians acknowledged many presumptively missed opportunities to identify, support and advocate for patients experiencing IPV prior to the intervention.
In this study, we explored the process of academic detailing for IPV including the physicians' reported experience. This is the pre-specified qualitative arm of the same pilot study. We use qualitative methods to explore the process of academic detailing and mechanisms for improvement in physician confidence and competence in counseling patients about IPV.