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Finding the right words: Provider-patient discussions can help domestic violence victims speak up

December 07, 2007

Probing questions boost disclosures of abuse, Penn researcher finds

PHILADELPHIA - Researchers at University of Pennsylvania School of Medicine and other sites have found that doctors and other health care providers can better their chances of identifying and helping victims of domestic violence by changing the way they ask patients questions.

In a large study recently published in the Annals of Internal Medicine, researchers found a number of communication pitfalls when emergency care providers discussed domestic violence with patients. Some examples: Providers often stumbled over their words, failed to acknowledge a disclosure of abuse or abruptly changed the subject. Occasionally, they screened for abuse in the presence of the woman's partner.

The study also revealed several best practices for communications. Follow-up questions and open-ended queries, for instance, were found to be helpful in prompting patients to disclose abuse. Patients also tended to open up to providers who showed empathy and concern or those who followed up on non-medical "clues" raised by patients, such when the patient talked about "stress."

"We found that probing - asking even one more question - was associated with almost three times the rate of patient disclosure of experiences with abuse," says lead author Karin V. Rhodes, MD, MS, Director of the Division of Health Policy Research in Penn's Department of Emergency Medicine.

Previous studies showed that patients can be hesitant to disclose their abuse experiences to doctors, but information was scarce about why communication breaks down. To get clues into what happens during these private talks, investigators audiotaped 293 emergency room interactions that included a discussion of domestic violence. Seventy-seven patients disclosed experience with domestic violence during the interviews. Researchers identified several strategies that seemed to prompt more disclosure of abuse, highlighting the need to ask open-ended questions that didn't use phrases like "victim" or "domestic violence," which require the woman to view herself as a victim. Re-framed queries such as "Has anyone ever treated you badly or made you do things you don't want to do"" or "Is there anyone you are afraid of"" tended to elicit disclosures, as did asking empathetic follow-up questions when patients mentioned other psychosocial problems.

The investigators pointed out that while better communication strategies were likely to open the door to meaningful conversations about abuse, patients appreciated being asked about the issue even when the provider asked about abuse in an awkward manner or stumbled over their words. Patients were more likely to rate their satisfaction with the visit as very high if there was any mention of the topic of domestic violence, even if they did not disclose abuse.

The research also revealed problems with provider action once disclosures are made. Less than a quarter of women who revealed abuse were referred to legal or counseling services, and providers generally failed to document domestic violence in the medical record -- something that can be helpful if an abused woman ultimately files criminal charges against her partner or seeks protection in civil court. These lapses occurred despite annual domestic violence education programs in each department studied and each provider's awareness that they were being taped.

University of Pennsylvania School of Medicine