Who’s Problem? Screening for Interpersonal Violence in ERs

A pregnant woman comes into an emergency room on a weekend evening. She reports that she fell on her stomach and is worried about her unborn child. The woman also has some minor bruising around her wrists and arms not consistent with this most recent injury. Is it the responsibility of an emergency room physician to screen this woman for interpersonal violence, more commonly referred to as domestic violence?

The American Medical Association (AMA) recommends universal screening of all women requesting services at emergency rooms. In some respects this makes good sense. Unlike TV dramatizations most females experiencing interpersonal violence do not walk around with black eyes and other glaring signs of physical abuse. Assessing all female patients for interpersonal violence, regardless of stated reason for entering the ER, can increase the number of women identified and referred to potentially desired resources. In the rush to get through high case loads, emergency room doctors may over look, or misunderstand signs of interpersonal violence, unless specifically screening for them. Despite the recommendation of the AMA for universal screening of interpersonal violence and the large body of evidence suggesting that emergency rooms provide a conduit to access women at high risk for interpersonal violence, screening does not consistently take place in ERs across the country. Recent work by Sormanti and Smith (2010) looked at the attitudes of ER physicians about universal screening for interpersonal violence.

Emergency room doctors listed a variety of reasons why they did not think ER physicians should screen for interpersonal violence. These range from belief that asking screening questions would offend female patients and potentially result in complaints to concerns over already high caseloads and the increased time and paper work required to screen all female patients for interpersonal violence. Doctors also expressed concern about not having specific knowledge and training about interpersonal violence and the proper steps to take (hospital protocol) if suspected in a patient. In fact, half of the ER doctors Sormanti and Smith spoke with did not know if their hospital had any kid of interpersonal violence protocol. Even before entering residency and the hospital setting physicians in training receive the implicit message that interpersonal violence is not an issue that falls within their purview. The average physician receives a total of two hours of training on interpersonal violence during the course of medical school.

Sormanti and Smith (2010) bring up important issues about the structure of our medical system, emergency medical services and ethical quandaries the medical profession must grapple with. Ample data exists, and common sense supports, the statement that large numbers of victims of interpersonal violence pass through ER doors. Only a fraction of these cases are identified within emergency room walls and referred for services. If the medical profession acknowledges the responsibility to screen for interpersonal violence in ER settings (e.g. AMA recommendations) and provide victims with service options, then medical training from its infancy and hospital protocol need to reflect this. Future physicians should spend more than the sum total of two hours during the course of medical school learning about issues surrounding intimate partner violence, barriers to resources and effective methods to communicate and support victims. Physicians that do not that learn interpersonal violence is not just an issue for social workers or psychologists, but a medical issue as well, may not buy into the idea that they have some responsibility to look for and address it within their caseloads. Likewise, medical facilities and ERs need to rigorously develop, support and enforce screening protocols for interpersonal violence. Developing a protocol, even a fantastic protocol, that half your staff physicians do not know about, means at best you effectively serve half of your target population. Even if ER doctors know an effective protocol for interpersonal violence screening, they need to have consistent support services at their disposal to effective use that protocol. It does very little good to invest in developing a protocol and training physicians, if a physician cannot locate a social worker to provide information and follow-up services after identifying a victim of interpersonal violence. Rectifying these issues will ultimately require a change in values within medical schools and residency training as well as the financial commitment of hospitals to develop and support effective protocols for intimate partner violence screening.

Sormanti M, & Smith E (2009). Intimate partner violence screening in the emergency department: U.S. medical residents’ perspectives. International quarterly of community health education, 30 (1), 21-40 PMID: 20353925