Doctors vs Domestic Violence

Yes, you can make a difference

Intimate partner abuse is as common—and as much of a medical problem—as smoking, hypertension, and other ills that you routinely ask patients about.

By Gail Garfinkel Weiss
Senior Editor

The patient, a healthy, 23-year-old woman working for a high-tech software company, had come to Boston Medical Center for a pre-op check on a fractured ankle. A resident examined her, took the necessary history, and brought the necessary forms to internist Elaine Alpert for her signature. Alpert looked them over and asked a question: How did the patient break her ankle?

She fell, the resident said with a shrug. Probably a sports injury, he figured. Alpert wasn't convinced. She told him to go back to the patient and say, "Very often, when we see a woman with an injury, it's because someone hurt her or was trying to, and she was attempting to get away. Did anything like that happen to you?"

As it turned out, the patient's estranged boyfriend had come at her with a broken bottle. As she tried to flee, she fell and broke her ankle.

Alpert, now assistant dean for student affairs at Boston University School of Medicine, is one of an increasing number of prominent physicians working to change the tacit "don't ask, don't tell" policy that has long characterized the physician's role in domestic violence. "Most doctors are well-intentioned, altruistic, and want to do the best they can for their patients," says Alpert. "But it's very hard to integrate a completely new aspect like domestic violence when most doctors didn't learn anything about it in medical school or residency training. They perceive that they have neither the time nor the expertise to deal with it effectively. So the natural inclination is to ignore it altogether."

Not only does that help perpetuate an ongoing social issue, it isn't good medicine. Until their core problem is addressed, domestic violence victims will continue to present with injuries, and with symptoms—like headaches and abdominal distress—that often result in expensive but unrevealing tests.

More likely than not, some of your patients are victims of intimate partner violence. A survey released this July by the US Justice Department and the Centers for Disease Control and Prevention indicates that each year about 269,000 women and 54,000 men seek physician care after being assaulted by a current or former spouse, boyfriend, or girlfriend.

Convincing victims that they can confide in you

"Physicians are key players in the process of treating domestic violence victims," says Kim Bullock, an assistant director of the emergency department at Providence Hospital in Washington, DC. Not only that, physicians may be the only professionals a domestic violence victim sees, and study after study shows that many battered patients would reveal the true nature of their injuries—if only they were asked.

Why aren't these patients more forthcoming without being prompted? Fear, of course. Surprisingly, hope is a factor, too. According to Robert Morrow, a family physician at Montefiore Medical Center in New York City, "we've had patients say they didn't tell us about victimization because they felt they could handle the problem themselves, or they thought things would change." And some assume—often correctly—that their doctor would rather not know.

It's up to you to convince them otherwise, if only because getting to the root of their problem will let you treat them properly. The AMA, in its booklet, "Diagnostic and Treatment Guidelines on Domestic Violence," recommends "routine screening of all women patients in emergency, surgical, primary care, pediatric, prenatal, and mental health settings." Some doctors, including Elaine Alpert, habitually screen men, too. Men are even more loath than women to identify themselves as victims of domestic violence, but sometimes they are (see "When the abused partner is a man"). The problem cuts across racial, economic, social, and gender lines, and both sexes can be victims in either hetero- or homosexual relationships.

Asking about domestic violence needn't take more than a minute or two. But it does require a certain amount of finesse. Questions like "Are you a victim of domestic violence?" or "Is your spouse beating you?" are too raw-edged and usually elicit a No. Family practitioner JoDean Nicolette, who studied the subject during her residency at the University of California at Davis, says, "It has never occurred to some people that they are abused, nor is it comfortable for them to claim it as part of their identity. A similar type of denial occurs with many chronic illnesses: coronary disease, alcoholism, depression, and lung disease from smoking. Some people don't see themselves as victims because they are 'merely' pushed or grabbed, not hit with a fist. Or they may feel that this is a normal part of relationships."

But the very fact that a health professional is asking about violence sets it apart from normal behavior and, in Alpert's words, "puts it on the table as a legitimate health care issue." Like substance abusers and smokers, though, abused women and men tend to be "difficult" patients. Not only might they fail to recognize they have a problem, but they may ignore your recommendations. "You may not get a response this visit, the next, or a year later," Bob Morrow concedes, "but when you ultimately do, it can be very gratifying."

Morrow usually begins an assessment by saying, "As domestic violence is very common in our society, I'm asking all my patients about it, so I don't miss any problems." Psychotherapist Esther Miller, director of Transitions Counseling Center in Cooperstown, NY, recommends asking patients, "Is anyone hurting you at home?"

The AMA, which suggests phrasing questions in your own words, offers the following examples:

• Are you in a relationship in which you've been physically hurt or threatened by your partner? Have you ever been in such a relationship?

• Are you (have you ever been) in a relationship in which you felt you were treated badly? In what ways?

• Has your partner ever destroyed things you cared about?

• Has your partner ever forced you to have sex when you didn't want to? Have you been forced to engage in sex that makes you feel uncomfortable?

• We all fight at home. What happens when you and your partner fight or disagree?

• Do you ever feel afraid of your partner?

Increasingly, medical groups and hospitals are developing their own domestic violence protocols. Emergency physician Ellen Taliaferro, medical director of the Violence Intervention and Prevention Center at Parkland Memorial Hospital in Dallas, says that Parkland has a screening tool called HITS. It consists of four questions: Does your partner hurt you? Insult you or talk down to you? Threaten you with harm? Scream or curse at you? The questioner scores one point if the answer is "never," two points if the answer is "rarely," three points for "sometimes," four points for "fairly often," and five points for "frequently." A total score of more than 10 points, Taliaferro says, indicates abuse.

How you ask is important, but not nearly as important as putting the issue on the table. "No one has ever gotten angry at me for asking," says JoDean Nicolette, "and I've been thanked countless times. The thing that stands out in my mind is how grateful patients are that you've cared enough to question them."

Going beyond routine questioning

Domestic violence, as the name implies, generally isn't a "silent killer," like an aneurysm that suddenly bursts. "It's usually very noisy," says Terri Pease, program director of the Partnership to Prevent Domestic Violence, in New York City. But symptoms can be subtle. California-based ER physician Patricia Salber, who with Ellen Taliaferro heads the advocacy group Physicians for a Violence-Free Society, confirms that "violence can present in many ways, and in people you wouldn't expect." Medical visits often result not from blunt trauma, but from the psychological wear and tear of being intimidated, terrorized, stalked, or made to feel worthless.

"Key symptoms," Bob Morrow says, "are headache, abdominal pain, pelvic pain, upset stomach, dizziness, panic, insomnia, and general malaise. Other particulars are unexplained bruises, evasive answers, and—especially—injuries that aren't consistent with the story being told. Panic or depression is a red flag." In addition to these, Kim Bullock watches for:

• Injuries in various stages of healing.

• Pattern injuries—those in which a hand or finger mark, or a shoe tip, belt buckle, signet ring, cord, or other object is outlined on the body.

• Defensive injuries, such as those to the midulnar region.

• Injuries to the head, neck, upper body, and, in pregnant women, the abdominal area.

"It's important," Bullock advises, "that the patient wear a gown during an examination, since clothing and jewelry are often used to hide nonaccidental injuries." Be alert, too, for patients who delay seeking medical care. "Ordinarily," Miller explains, "a person comes in right after an injury. But very often, domestic violence victims wait until they can't not see a doctor."

If you have reason to suspect abuse but the patient brushes off your initial queries, you might have to try another tack. "Sometimes I have to ask three times, in different ways," Nicolette says. "I might ask, 'What does your partner do when he gets angry?' or 'Is it safe for you to go home?' " Bullock also becomes a bit more probing. "I'll say something like, 'What you've just told me doesn't explain your injury. Is there a reason you're hesitant to tell me more about it? Is there something else you'd like to say?' Sometimes that helps the patient realize that you're trustworthy, and she can tell you what's happening to her."

Few things raise Nicolette's antennae as much as a hovering, overbearing partner. "This frightens a lot of physicians," Morrow acknowledges. "But as I point out to doctors, if you're scared by this person, think how the woman who has to live with him must feel." Morrow deals with such situations by stressing his own discomfort in having another person in the room while he's examining a patient. "I'll tell the partner that I don't allow a third party in my examining room," he says. Alpert thinks this should be dogma in all medical settings, "just as the airlines enforce 'ticketed passengers only beyond this point' rules."

Deciding what to do when the answer's Yes

"When a patient acknowledges that she's being abused, a number of things come into play," says Kim Bullock. "First, confirm that you believe her and that your conversations will remain confidential." This is crucial, Patricia Salber notes, "because if you don't validate the patient's experience, she'll think she shouldn't have said anything. That colludes with the perpetrator, because he has probably told her that no one is going to care."

Educator and activist K.J. Wilson, a domestic violence survivor and author of the book When Violence Begins at Home: A Comprehensive Guide to Understanding and Ending Domestic Abuse (Hunter House, 1997), agrees. "A big part of what keeps us in violent relationships is the isolation we experience," she says. "When that isolation begins to crack a little bit by one person reaching out, it tells the survivor that getting help is possible."

That help need not extend beyond giving the patient the number of the National Domestic Violence Hotline (800-799-SAFE) or referring her to a local domestic violence expert—a social worker trained to deal with victims of intimate partner abuse, say. If the patient has access to the Internet, tell her about the many Web sites that have information on the subject (see "Telephone and Internet information resources").

Better yet, facilitate the referral yourself, as you would when directing a patient to a dermatologist or cardiologist. "If the patient has a heart problem," Salber points out, "you wouldn't just say, 'You have a serious problem. Now here's a phone number,' and leave it at that. You'd make an introductory phone call. Do the same for domestic violence victims. Know who the local experts are, form relationships with the advocacy people, and ring the bell when you need them. Let them take over the case."

Handouts can be helpful, but be sure to ask the patient whether she has a safe place to store such material, because batterers often go through their victims' belongings. You can give the patient a prescription sheet or a small card with national and local hotline numbers but without other identifying information. Something that small can be tucked into a purse—or even a shoe. It's also a good idea to have cards or tear-off sheets available in your waiting room and office lavatories, so patients can help themselves.

Prominently displayed posters indicate that you take the subject of domestic violence seriously, and they might encourage patients to confide in you or at least take a tear-off sheet or card. The Family Violence Prevention Fund, a national organization that focuses on domestic violence, has a federally funded National Health Resource Center on Domestic Violence (www.fvpf.org/health/index.html; 888-RX-ABUSE) that offers health care professionals free technical assistance and educational materials for themselves and their patients. The organization also sells posters, publications, and training tools.

The American College of Obstetricians and Gynecologists (www.acog.org), the Minnesota Center Against Violence and Abuse (www.mincava.umn.edu), and Safe Horizon (www.safehorizon.org), among other organizations, can provide you with information, publications, and other products. "Not all patients want to admit abuse," Bullock says, "but they're eager to know that you'll be there for them if they want to come back and talk about it."

When a patient does admit to being abused—or your suspicion is reasonably strong—documenting the situation in the medical record becomes crucial. "These cases typically go on for years before any legal action is taken," says psychotherapist Miller. "That action could be a civil case, such as a divorce or a child custody hearing, or a criminal case if the victim is seriously injured or killed. And the medical chart might be the only existing evidence against the perpetrator."

It's important to word your chart notes carefully, Miller advises. "These victims' self-esteem can be nonexistent, and sometimes they'll say things like, 'It was my fault.' If the doctor records that on the chart, it could prove harmful down the road. It's better to write something like, 'Patient seems unsure; affect is teary.' " Similarly, Miller adds, when patients chalk up suspicious injuries to an accident, your chart notes might indicate: "Patient says she fell down the stairs, but injury is inconsistent with that explanation. Seems to have been hit with an object."

Be sure to include photographs in the record, even if the police take their own. "Health care providers' pictures carry more weight as medical evidence for prosecutors," says Bullock.

Physicians for a Violence-Free Society offers a documentation course for health care professionals. The four-lecture course teaches participants how to recognize "pattern" injuries that suggest domestic abuse, what constitutes effective medical documentation, and how to use a Polaroid camera and body maps to provide a visual record of injuries. Hard copies of the course, including slides and other materials, sell for several hundred dollars, but PVS (www.pvs.org) will send most of the materials via e-mail for $125, and the course is available free to PVS members.

So listen, refer, and document. But what you shouldn't do, stresses Salber, is just tell the victim to leave her abuser. "I think doctors get frustrated with domestic violence because getting the victim to leave is their goal," she says. "So if I'm seeing an abuse victim and she chooses not to leave that day, I feel I've failed, and I'm less likely to want to ask or intervene with the next patient. But if I understand that asking and validating is an important and effective intervention, then I don't experience that frustration."

Likewise, when Bob Morrow hands a phone number to a domestic violence victim, he usually says, "They will listen to you and offer some suggestions. You might not be ready to do anything, but why don't you call and find out what your options are? I care about you."

That type of approach helped Sherri Lee, a social worker in Washington, DC, extricate herself from a longtime abusive relationship. "A doctor looked me in the eye," she recalls, "and said, 'I think you are the neatest person. I realize that things are difficult at home, and if you need help, it's available.' " Lee, who now counsels victims of intimate partner abuse, stresses that doctors should resist the temptation to brush off battered patients with a psychological referral and a Valium prescription. "We need resources and referrals," she says. "We don't need doctors to push pills on us."

Understanding the laws that govern domestic violence

Unlike most conditions for which you see patients, intimate partner abuse often involves a criminal act. Does that mean you're obligated to call the police? It depends. If your practice is in California, for example, you must call the police, even if you're treating a patient with injuries you merely suspect were caused by abuse. Kentucky, another of a handful of states with mandatory reporting statutes, requires physicians to report domestic violence to the state Department for Social Services.

Some state laws specify that all intentional injuries must be reported; others mandate reporting only if an injury is extremely grave or was caused by a firearm. Most states, though, allow health care professionals a certain amount of discretion in deciding whether to contact legal authorities. That's fine by Elaine Alpert. "Mandatory reporting laws were designed with the best of intentions, but sometimes they put doctors in the position of having to go against the patient's wishes. And they often place the victim in more danger," she says, "because too few programs are in place to protect the victim over a long period of time."

The problem, as Ellen Taliaferro sees it, is that "politicians pass laws but don't embrace the whole issue. So if you pass a mandatory reporting law without legislating mandatory protection for the victim, the police might arrest the perpetrator—but he's out of jail the next day, and now he's really angry. So the victim is in for more abuse."

A related problem is that mandatory reporting laws may discourage victims from seeking medical help. A better approach, according to Taliaferro, is mandatory referral, which is the requirement in Texas. "If I see someone who I think has been a victim of domestic violence," she explains, "I'm mandated to (1) document it in the chart, (2) tell the patient that domestic violence is a crime, whether she confirms or denies my suspicions, and (3) give her a referral to the police and the local shelter. This allows her to decide what to do next."

Ariella Hyman, a San Francisco attorney at Bay Area Legal Aid, who has written extensively on the legal ramifications of domestic violence, questions the wisdom of laws mandating that physicians go to the police regardless of their patients' desires. "I think the health care system's role in domestic violence is different from the criminal justice system's role," she says. "It's up to the health care system to safeguard the health and well-being of patients, not to hold batterers accountable. If a battered woman believes police involvement would be beneficial, she can ask the doctor to help support her allegations. Otherwise, it's best for the physician to discuss with the patient her various options—shelter, restraining order, support group, and so forth—and help her access those she believes will enhance her safety and well-being."

Hyman doesn't know of any physicians being prosecuted or sued for failing to report domestic violence. Neither does Lisa James, program manager with the Family Violence Prevention Fund. "We absolutely support health care providers helping patients access the criminal justice system by documenting injuries and putting patients in contact with local law-enforcement authorities—but not without patient consent," she says. "Doing otherwise constitutes taking power away from victims and prevents them from making their own decisions. It's up to the patient to decide if calling the police will help her or endanger her more."

Addressing the issue in medical school

"When I trained, there was nothing in the medical textbooks about domestic violence," says Physicians for a Violence-Free Society's Patricia Salber. Recently, Salber looked through several medical school textbooks and found "good news and bad news. A lot of books now have chapters on how we should respond to intimate partner violence. But there are still some where you can't find it."

JoDean Nicolette, who graduated from the Stanford University School of Medicine in 1997, says, "In my medical school and residency, the faculty did provide information about violence. But at most schools, the students and residents collect the educational materials, bring in the lecturers, or present the topic themselves to get the education they feel they need."

Because of their limited exposure to the subject, students often don't absorb enough to apply it once they enter the high-pressure milieu of everyday practice. Moving intimate partner abuse closer to the core of medical training is the goal of family physician Michael A. Rodriguez, a member of the Department of Family and Community Medicine at the University of California, San Francisco School of Medicine. "The topic," Rodriguez says, "is not addressed in any consistent manner at medical schools in this country. So you have some, like UCLA, that have remarkable programs focusing on intimate partner abuse, and others that have nothing but a volunteer lecture."

Kim Bullock, who developed and teaches an elective on family violence at Georgetown University School of Medicine, stresses the importance of capturing a student's attention early—in the first year of medical school. But the message often isn't reinforced in residency or in CME, Bullock concedes. She finds it encouraging, though, that "even the HMOs have begun to develop curricula and best practices that include the identification and assessment of domestic violence."

Physician education is only part of the equation, Rodriguez believes. "Patients need to be educated, too, so we can stop taking a solely reactionary approach to domestic violence and start thinking about prevention," he says. "A good start is for pediatricians and family physicians who care for infants and youngsters to talk with parents about the dangers of intimate partner abuse and the importance of providing positive role models for children. And just as we talk to our adolescent patients about appropriate and inappropriate sexual behavior, we can help teens understand that intimate partner abuse is intolerable and destructive to family life."

Shedding more light on an enormous problem

"Because discussion of intimate partner abuse is still peripheral to medical education, new graduates don't feel comfortable dealing with someone who has been in an abusive situation," Elaine Alpert says. "They know what to ask, but they don't know what to do after that. They're unsure of their own skills."

Some doctors, however, have embraced the issue, as have a number of groups and hospitals—even entire towns. For instance, in rural Libby, MT, a small city in the northwestern part of the state, medical personnel, administrators, and social workers at the 29-bed St. John's Lutheran Hospital work together as part of a domestic violence task force. The brainchild of social worker Laura Sedler, the task force promotes a zero-tolerance community message and has developed guidelines for medical personnel and others.

The doctors and nurses at St. John's don't ask all patients about intimate partner abuse, says ER physician Jay Maloney. "But," he notes, "we always keep it in mind. If you don't do that, you miss too many of them. There are some cases where we didn't pick up on the earliest symptoms, and the next thing you know, the person was back in a week or two with another injury."

A major advantage of the task force, says St. John's CEO Rick Palagi, is that it uses a systems approach to involve a wide range of professionals—clergy, educators, police, doctors, nurses, and social workers—in a coordinated response. "By acting as a united front of agencies," Palagi says, "we're slowly making a difference in the community."

Bob Morrow participates in a similar effort in an urban setting. He and many of his colleagues have joined with Health Insurance Plan of Greater New York (an HMO) and Safe Horizon, a widespread network of New York City-based support and counseling services, to create the Partnership to Prevent Domestic Violence. The partnership trains physicians and other health professionals to ask about intimate partner abuse. Cases are presented on videotape, then discussed. "We've seen an increased awareness and referral pattern among the doctors who've been involved," Morrow says.

In the District of Columbia, first- and second-year students at the Georgetown University School of Medicine now organize an annual conference on intimate partner abuse. Students from other area medical schools attend, as do local practicing physicians. "What's so exciting about this project," says Kim Bullock, the conference's program director, "is that it's done on the students' own time, in addition to their heavy academic schedules. And it shows that educating physicians early on to be responsive to domestic violence can have a tremendous impact."

In a study by internists Nancy Kathleen Sugg and Thomas Inui, published in JAMA in 1992, only two of the 38 primary care physicians interviewed were comfortably able to ask patients about violence. The rest generally steered clear of the issue for fear of offending patients, because they weren't sure how to help, or because they assumed the problem was limited to socioeconomically disadvantaged groups. One respondent said, "You don't open a Pandora's box for the same reason you don't generally ask people, 'Do you have sexual problems?' Not because it is not important, but because you . . . don't have time to deal with all this."

Eighteen percent of Sugg and Inui's respondents used the "Pandora's box" metaphor, and several others mentioned "opening a can of worms." Sugg, who teaches at the University of Washington School of Medicine, believes that this attitude still prevails to a large degree, but she sees some positive signs. "Mainstream medical journals are now much more likely to feature articles about domestic violence," she says, "and I think there's a tendency in medical schools to make domestic violence—along with child abuse and elder abuse—a larger part of the curriculum."

But she doubts there's been any sweeping change in the attitudes of practicing physicians with regard to addressing domestic violence. Effecting such change is a major goal of activists working to reduce the incidence of intimate partner abuse. As Morrow puts it, "Your patient in her 40s or 50s is more likely to be a victim of domestic violence than of breast cancer. Yet we've all spent a lot of time discussing the importance of mammography, while virtually ignoring victimization. It's the elephant in the waiting room that no one sees."

This article published during Domestic Violence Awareness Month, is the first installment of a series..

When the abused partner is a man

Domestic violence is an issue that packs some surprises. Among them: In some localities, a significant percentage of the adults arrested for intimate partner assault are women. In Vermont, for instance, that was the case in nearly 25 percent of domestic violence arrests in 1999; in Concord, NH, the figure approached 35 percent.

These numbers might be deceiving. Sometimes, both parties are red-faced and bleeding when law enforcement officers arrive on the scene, so the police—few of whom are properly trained in this area—arrest everyone and ask questions later. Undeniably, a percentage of the women arrested for assaulting a domestic partner acted in self-defense or in retaliation for years of victimization. But just as surely, at least some of the intimate partner attacks on men are as unprovoked as the average mugging.

How many domestic violence victims are male? The estimates vary wildly, from 5 percent to more than 50 percent. No reliable figures exist on domestic violence injuries to males in homosexual relationships. Still, the US Justice Department's National Violence Against Women Survey, published this year, estimates that 1.5 million women and 835,000 men are raped and/or physically assaulted by an intimate partner annually in the United States.

This means the guy who tells you the large welt on his head is from a sports injury might have been on the receiving end of a lamp wielded by his significant other. Former broadcast journalist Philip W. Cook of Tualatin, OR, author of Abused Men: The Hidden Side of Domestic Violence (Praeger, 1997), says male victims of intimate partner violence are more likely than females to have groin injuries, and more likely to have been struck by objects or had things thrown at them.

When you see such injuries, therefore, a question like "Is anyone hurting you at home?" is probably called for. According to FP Robert Morrow, who works with Safe Horizon, a victims' advocacy group in New York City, "We don't routinely screen male patients for domestic violence, but certainly men who present with symptoms should be queried about it."

Emergency physician Ellen Taliaferro, co-founder of Physicians for a Violence-Free Society and medical director of the Violence Intervention and Prevention Center at Parkland Memorial Hospital in Dallas, concedes that male victimization in intimate relations is gravely understudied. "Unfortunately, it probably will continue to be for some time, because it's not where the greatest morbidity and mortality are," she adds. No doubt that's a major reason why most domestic violence literature, public awareness campaigns, and clinical protocols scarcely mention male victims. And why resources such as shelters and hotlines are geared almost entirely toward women. So even if you identify a male victim, there are few agencies or programs to which you can refer him.

Still, a handful of gender-neutral domestic violence services exist across the country, including the Valley Oasis Family Violence Shelter (661-945-6736) in Lancaster, CA, and the Florida Men's Resource Center, which lists several locations on its Web site (www.fmrc.themenscenter.com). Additionally, the National Domestic Violence Hotline (800-799-SAFE) offers 24-hour crisis intervention and referrals for men, women, and children. And the Portland, OR-based Stop Abuse for Everyone (SAFE) has a list of organizations that serve abuse victims on its Web site (www.safe4all.org).

Few handouts on male victimization exist. One of them, a brochure from Arrowdot Productions, is titled "Are you (or someone you care about) a male victim of intimate partner violence?" It lists the signs of domestic violence and has sections on how men cope, why they stay in abusive relationships, and what they should do. For a free copy, send a stamped, self-addressed envelope to Arrowdot Productions at PO Box 951, Tualatin, OR 97062. Additional copies cost about 20 cents each.

Coding for domestic violence isn't as easy as ABC

Data distributed by the AMA suggest that 22 to 35 percent of all women seeking medical attention in an ER are victims of domestic violence. Yet a University of Mississippi study of Health Care Utilization Project data found that only seven out of every 100,000 hospitalized patients have domestic violence codes in their records.

In part, the lack of documentation is due to doctors' unfamiliarity with the ICD-9-CM codes for domestic violence (more on those later). But another problem is the financial disincentive to code properly. In 1996, the Coding Clinic, a quarterly newsletter published by the American Hospital Association, recommended listing domestic violence as the primary diagnosis (PDX), with the presenting condition as the secondary diagnosis. The idea was to more accurately document the extent of the problem. Coding this way, however, usually lowers the reimbursement.

Further complicating matters is the fact that E modifier codes—which provide concrete information about the acts of violence—aren't required. Moreover, no specific CPT codes exist for care given to victims of domestic violence in physicians' offices and other outpatient sites.

The paradox is that the solution to the current coding and reimbursement problems lies in getting physicians to do a better job of documenting domestic abuse now. "Thorough and comprehensive documentation and coding of domestic violence would promote the collection of more accurate data on the impact of domestic violence on the health care system," says Lisa James, program manager with the Family Violence Prevention Fund in San Francisco. "This data could then support both the 1996 proposal to increase the reimbursement level for ICD-9-CM codes attached to domestic violence interventions, and the creation of a much-needed CPT code for domestic violence. Both these steps could enhance the identification—and prevention—of domestic violence when seen in outpatient settings."

So how should you code a patient visit that involves domestic violence? Here are some guidelines:

• Use the ICD-9-CM codes for domestic violence. Those range from 995.80 to 995.85, although it's best to avoid 995.80, which generally isn't specific enough.

• Include another ICD-9-CM that specifies the presenting problem, such as 802.20 (fracture of the jaw).

• Also include the appropriate E modifier codes to identify who committed the act of violence, the nature of the act, whether it was inflicted accidentally or purposely, and other details.

• Use history codes, such as V15.41 (physical abuse and rape) and V61.11 (counseling for the victim), to describe past episodes or the need for counseling.

• Until an appropriate CPT code is created, use the existing ones, such as care plan oversight (99374-5) or preventive medicine service (99381).

—Anne L. Finger,
Senior Editor

Telephone and Internet information resources

Here's a list of some of the many domestic violence resources available for health care professionals and their patients. Most of the Web sites contain links to other useful sites that offer medical, legal, and financial information, bibliographies, and advice on how to access shelters, social service agencies, legal assistance, and other community programs. Victims concerned that their abusers might trace the Web sites they've visited should be advised to access the Internet at a public library or community center. Telephone numbers are included for individuals who don't have Internet access.

National Domestic Violence Hotline
www.ndvh.org800-799-SAFE

This 24-hour hotline fields more than 100,000 calls annually from abuse victims. Callers speak with a trained advocate who can intervene in a crisis, offer support, and provide referrals to services in their communities. English- and Spanish-speaking counselors are available at all times, and interpreters can be summoned as needed. Callers from all 50 states, the District of Columbia, Puerto Rico, and the US Virgin Islands can dial the toll-free number. The Web site has domestic violence statistics, a list of abuse indicators, and links to other sites.

Family Violence Prevention Fundwww.fvpf.org415-252-8900

This San Francisco-based nonprofit organization's Web site has information on public policy initiatives, protecting children in a violent home, violence in the workplace, and other issues. The fund's National Health Resource Center on Domestic Violence (www.fvpf.org/health; 888-RX-ABUSE) features publications, technical assistance and model training strategies for health care professionals, as well as a news archive, press releases, and information on screening to prevent abuse. Click on Practical Tools to order "patient safety cards" with phone numbers of local domestic violence programs and "practitioner reference cards" that outline the steps physicians can take to help abuse victims.

National Coalition Against Domestic Violence
www.ncadv.org303-839-1852

In addition to listing state coalitions and other programs throughout the US, this site features information on public policy and links to other sites. The Getting Help section includes information on safety planning, workplace guidelines, and legal guidelines. Products such as books, pamphlets, posters, and bumper stickers can be ordered online. The coalition is located in Denver.

Minnesota Center Against Violence and Abuse
www.mincava.umn.edu612-624-0721

The center, housed in the social work school of the University of Minnesota, St. Paul, has an extensive Web site that covers violence as it relates to dating, drugs, elders, disabilities, school, and a wide range of other topics. It also has information on survivor resources, speakers and trainers, and violence prevention. A Health Care section features scholarly papers and links to other Web sites.

Safe Horizon
www.safehorizon.org212-577-7700

Safe Horizon (formerly Victim Services), located in New York City, is a service, research, and advocacy organization for abuse and assault victims in the city's five boroughs. The organization's Web site, however, is national in scope and has links to more than 100 sites across the country. Separate links focus on domestic violence and dating-related abuse, elder abuse, help for men who batter, men who are abused, stalking, and other issues. Clicking on Domestic Violence Shelter Tour brings you to a map; then click on your state to get the name, address, and phone number of the state's domestic violence coalition, as well as a link to a wide-ranging resource page.

San Francisco Medical Society
www.sfms.org415-561-0850

Click on Resources, then on Domestic Violence Brochure, to access "Domestic Violence: A Practical Approach for Clinicians," an online publication to assist doctors and other health care personnel in working with domestic violence victims. The brochure, adapted by the society from the San Francisco Domestic Violence Health Care Protocol, has details on risk factors, interventions, documentation, and other aspects of domestic abuse.

Emerge
www.emergedv.com617-547-9879

The Web site of this Cambridge, MA-based batterers' treatment program has details on how such programs work. It also provides links to groups serving neglected populations, including Advocates for Abused and Battered Lesbians, Ayuda (resources and information about the rights of battered immigrant women), and the Women's Rural Advocacy Program (WRAP) quarterly newsletter.

American Bar Association Commission on Domestic Violence
www.abanet.org/domviol/home.html202-662-8637

In addition to links to related sites and important telephone numbers, this section of the ABA's Web site has many articles, including "How an abuser can discover your Internet activities," "Five ways to fight domestic violence," and "If you want legal assistance but cannot afford a lawyer."

US Department of Justice Violence Against Women Officewww.ojp.usdoj.gov/vawo202-616-8894

The Web site has information on model violence prevention programs, a place to post comments and questions, and lists of state hotlines, coalitions, and advocacy groups.

MEDICAL ASSOCIATIONS

The AMA's Web site (www.ama-assn.org) has many articles on family violence. (Click on Consumer Health Information. Then, under Healthy Family, click on Women's Health, then on Violence). You can also order the association's diagnostic and treatment guidelines on domestic abuse, elder abuse and neglect, and the mental health effects of domestic violence (call Mary Haynes, 312-464-5563).

The Web site of the American College of Obstetricians and Gynecologists (www.acog.org) contains a comprehensive Violence Against Women section that includes fact sheets, links to state coalitions, advice to physicians, and information on how to order a CME video and monograph, technical bulletins, posters, handouts, and patient pocket/shoe cards.

Help for batterers who want to change

The classic no-win question, "When did you stop beating your wife?" has a somber undertone in that it acknowledges the ubiquity of intimate partner abuse. So just as some of your patients have likely been battered by a spouse, boyfriend, or girlfriend, your patient roster probably includes a batterer, or perhaps several.

Identifying batterers is tricky, though, and not just because there's no stereotypical abuser. Psychologist David Adams, founder of the Cambridge, MA-based Emerge, the nation's first batterer-treatment program, confirms that batterers often rationalize or minimize what they're doing, or they present themselves as victims. "It's part of their denial," he says.

Family practitioner JoDean Nicolette observed this phenomenon firsthand during her residency at the University of California, Davis. "I saw a guy who had just gotten out of jail," she says, "and when I asked him why he'd been locked up, he replied, 'Because I didn't go to some classes.' It turned out that he had pleaded guilty to spousal abuse, but his sentence was suspended on the condition that he attend a batterer treatment program. He didn't keep his end of the bargain, so he wound up in jail. But to his way of thinking, he'd been imprisoned because he didn't go to class, not because he beat up his partner."

Getting batterers to enter—and remain in—a treatment program, therefore, first involves breaking through that wall of denial. You can try doing that by including a few pointed queries on your medical history questionnaire—such as "What happens when you and your partner argue?" "What's the furthest you've ever gone with your anger?" and "Have you or your partner ever been injured during an argument?" When you interview patients, Adams says, be alert to derogatory references toward a partner, and to the use of terms like "not getting along," "temper," and "self-defense."

Patients who have substance abuse problems are more likely to be batterers, Adams points out, but he believes neither alcohol nor drugs cause battering. Indeed, one of the key tenets of Emerge is getting offenders to admit that they're solely responsible for their violent actions. Batterers learn healthy coping and communication skills as alternatives to coercive and abusive behavior. The 40-session program is primarily for men who abuse their female partners, but Emerge also has treatment programs for homosexual men and women. Participants remain in the program for as long as two years.

When referring someone to a batterer treatment program, stress that violent behavior isn't likely to abate on its own, but reassure the individual that help is available, Adams says. There's no national directory of such treatment programs, so you might have to do some research to locate one in your area. Adams suggests starting with the Denver-based National Coalition Against Domestic Violence, which has a state coalition list on its Web site (www.ncadv.org). Most of these coalitions provide referrals to shelters and other support services for victims, but many have information about state-certified programs for batterers, too. The National Coalition's telephone number is 303-839-1852.

The American College of Obstetricians and Gynecologists also lists state coalitions at www.acog.org. To access the list, click on Violence Against Women. To find out which batterer treatment programs are state-certified, call the Minneapolis-based Battered Women's Justice Project at 800-903-0111.

 

Gail Weiss. Doctors vs domestic violence: Yes, you can make a difference. Medical Economics 2000;20:40.