Medical response to domestic violence nationwide may be getting better, but it still needs improvement.

A UCSF study -- one of the few to examine domestic violence in relation to health care -- is focusing solely on survivors of domestic violence who have had positive experiences with physicians. The lessons will hopefully help others in the frontlines of health care play a more active and definitive role in addressing a growing problem.

“People who have had positive experiences are hard to find, and one goal of this study is to develop practical and effective ways for physicians to provide better health care to victims of domestic violence," says study leader Barbara Gerbert, PhD, chair of the Division of Behavioral Sciences in the UCSF School of Dentistry.

Domestic violence is a leading cause of injury among women -- resulting in 21,000 hospitalizations, 99,800 inpatient days, 28,700 emergency department visits, and 39,900 doctor visits annually in the U.S., according to Gerbert. Many physicians, however, do not know how to react to domestic violence effectively, she says.

Physicians are not required to attend training programs on domestic violence, although most emergency rooms do have protocols for battered patients. The protocols specify, among other instructions, what signs to look for, what questions to ask victims, and when referrals should be made to social services agencies. "Unfortunately, these considerations are barely covered in medical schools or during residencies," Gerbert says.

“It’s been called the fear of opening Pandora’s box," she adds. "Some physicians feel that they don’t know what to do, or that they may do more damage than good by trying to help patients.”

Gerbert has found the most effective way to gather information that can help meet the goal of the study is to enroll participants who are willing to share their personal stories with researchers. All study information is used only for research purposes, she emphasizes.

UCSF researchers already have conducted face-to-face, confidential 2-3 hour long interviews with 30 survivors of domestic violence in the Bay Area. Gerbert now plans to extend the study, which is funded by a $1.5 million grant from the National Institute of Mental Health, to include more survivors in the Bay Area and across the nation.

The researchers are seeking 20-30 more English-speaking people to participate. Those who fit the study criteria and complete the interview will receive $100. Participants must meet the following requirements:

• be a survivor of domestic violence who got out of a physically abusive relationship
• have had a positive experience with a medical doctor during the relationship
• currently live in a safe environment

The research team is also recruiting emergency department, primary care, and ob/gyn physicians who feel they are doing a good job caring for survivors of domestic violence, or have had positive experiences with battered patients. Physicians who meet the study's criteria will participate in focus groups in which they will share their information.

Gerbert says that by including these physicians in the study, she hopes to prompt others to consider domestic violence as a cause of physical injury and other health problems. Physician involvement also will provide the study with information and examples of how to deliver better, more effective health care to battered individuals.

In one case, for example, a study participant reported that she and her primary care physician did not openly discuss her abuse because she sensed that her physician knew she was uncomfortable in doing so. However, the physician carefully documented the injuries, implying that these documentations were available for future reference. The woman understood this process as a code for acknowledging the continuous abuse, Gerbert says.

This case demonstrates that some people are looking for a level of covert understanding, she adds. “We call it the ‘dance of disclosure.’”

According to Gerbert, many study participants have said that physician affirmation of their abuse did not prompt them to leave their partners immediately, but for many it was an essential part of their move to safety.

When physicians told them that they did not deserve the abuse, it made them question their partners' actions, because they considered their physicians to be authoritative, trustworthy people, she explains. "In some cases it planted the idea of leaving an abusive partner."

Gerbert says it is important for physicians to identify the victim, validate the experiences, refer patients to other advocacy services and shelters, and thoroughly chart and document injuries.

Another emphasis of the study is to show that abuse can happen to anyone -- men or women, those in same- or opposite-sex relationships, and people of any age or socioeconomic status, says Gerbert. “What we are trying to do is make sure that all health care professionals realize that there are people in their practices who may be abused and that they can’t guess who those patients might be.”

Survivors of domestic violence and physicians who are interested in participating in the study or would like more information are encouraged to call the toll free number 1-800-859-8389, Monday-Friday, 9 a.m.-5 p.m.

By Lordelyn del Rosario

1st appeared 11/24/97

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