by Ellen Taliaferro, M.D., F.A.C.E.P. and A. Morgan Baker
by Ellen Taliaferro, M.D., F.A.C.E.P. and A. Morgan Baker
Domestic violence is one of the least reported and most statistically astonishing health issues facing our society today. If perceived and treated like any other illness, it would be diagnosed as frequently as breast cancer -- if not more so -- and far more frequently than hypertension, colon cancer, hepatitis and many other medical conditions for which health providers routinely screen and treat.1
While cost estimates for treating victims of domestic violence vary, the price of fear, pain, injury and loss of life to domestic violence is unfathomable. In the United States, 95 percent of its victims are women,2 a woman is physically abused by her husband every nine seconds,3 and half the women murdered each year are killed by their male partners.4
Fortunately, we have taken great strides toward exposing and treating this non-discriminating condition that challenges the emotions and discretion of everyone exposed to it -- from the victims and their families, to health and community service providers, to the justice system at large. Armed with training, a Polaroid Spectra camera and the willpower to acknowledge and battle this dark epidemic, the strategy for many health and law professionals nationwide is three-fold: ask the question, take the picture and break the cycle.
Even in the medical arena, the challenges of facing and fighting domestic violence loom greater than ever before. It takes training, courage, time and sensitivity to recognize, inquire and properly document the results of a domestic violence situation. But to effectively break the cycle of domestic violence, one must have a thorough understanding of its repetitive and escalating nature. A push or shove today becomes a kick or a head-blow tomorrow. The injuries worsen as the cycle continues over time.
"What we're really trying to change is behavior," explained Kara Laverde, coordinator of the Family Violence Program at Providence Health System. "In studies that show the barriers to physicians dealing with the domestic violence-related issues of their patients, lack of time is a big factor, and meeting productivity standards is a big, constant pressure."
For Laverde and other program implementers, persuading caregivers to open the "Pandora's Box" on domestic violence isn't always easy. Fortunately, in some parts of the country legislative mandates now require medical personnel to document and report domestic violence injuries. In addition, since 1991 the Joint Commission for the Accreditation of Hospitals and Health Care Organizations (JCAHO) has required healthcare organizations to adopt JCAHO's domestic violence standards into their emergency room protocol. Still, long-term reasoning and economic logic play a key role in the domestic violence training equation.
Linda Olsen, a shelter director for the Eastside Domestic Violence Program in King County, Wash., put the argument for intervention in simple terms: "The more quickly police, hospital staff members, employers and other service providers intervene in a domestic violence situation -- rather than waiting until the situation escalates over time -- the faster a woman will realize that she doesn't need to be victimized." That realization is a critical link in breaking the cycle of domestic violence.
Through a
widespread collaborative effort between law enforcement, healthcare
providers and community-based programs like the Eastside Domestic
Violence Program, Seattle is one of many metropolitan areas across
the country taking a stand against domestic violence. Effective
weapons in this fight include the Polaroid Spectra cameras police use
for documenting domestic violence injuries and crime scenes, and
medical personnel use to document victims' injuries.
"We're saying (to our medical personnel), 'documenting domestic violence makes your life easier,' " said Laverde. "Proper documentation, with photos and written reports will help your patients -- either now or in the future -- and help protect you from lawsuits."
"Part of our 'sell-in' for photo and written documentation of injuries is telling people that detailed records can help decrease healthcare costs by helping victims take a legal stand against their abusers -- thus, stopping the cycle of domestic violence before the victim is injured again," said McGrogan, manager of the social services program for Scripps Health in San Diego. "We also stress that photographs often eliminate the need for medical personnel to appear in court -- a huge benefit for practitioners, nurses and other hospital personnel because they don't get paid to spend a day in court."
While various types of photo and video documentation exist, many care providers utilize instant cameras because the photographs are solid, tamper-proof evidence available for review within minutes after they are taken.
Many healthcare providers on the leading edge of proactive domestic violence intervention are years away from gauging any quantitative financial impact gained from practicing effective domestic violence intervention. However, some reports shed light on the financial toll domestic violence currently inflicts on our medical establishment and our society as a whole.
A study conducted by the Rush Medical Center in Chicago found the average charge for medical services to abused women, children and seniors was $1,633 per person per year.5 Another study conservatively estimates that medical expenses from domestic violence total at least $3 to $5 billion annually.6
But the above figures only scratch the surface of the
multi-billion dollar burden domestic violence places on taxpayers and
the medical society when one considers the following: Between 22
percent and 35 percent of women visiting emergency departments in the
United States are there for symptoms related to ongoing abuse. In
addition, families in which domestic violence occurs use doctors
eight times more often, seek emergency room treatment six times more
often, and use six times more prescription drugs than the general
population.
There also are the incalculable costs related indirectly to this epidemic, such as homelessness, birth defects, alcohol and drug abuse, unemployment, etc. In the workplace alone, it is estimated that businesses forfeit $100 million or more annually in terms of lost wages, sick leave, absenteeism and non-productivity.
McGrogan estimates that by the year 2000, Scripps will be the primary HMO for 1.25 million people under managed care insurance.
"Our organization only gets so much money to treat each person," says McGrogan. "That's why we feel it's important to screen for family violence just like we screen for alcohol abuse, drug abuse, mental illness and other various bio entities. Through early detection at the primary care level, we can do our part to minimize the number of victims who will come back to our hospitals and clinics in the future -- possibly in need of an MRI, Emergency Department treatment or lengthy hospitalization."
Bobbi Famularo, a northern California-based regional maternal child coordinator for Kaiser Permanente, agrees with the early detection strategy. "There's a tremendous value in intervening so that continued utilization of healthcare and adverse outcomes to the victim and family don't take place over a lifetime."
Training in documentation is key according to Mary Anne Nolan, clinical coordinator of emergency services at Columbia Deering Hospital in Miami. In recent years, Columbia Deering has developed a model standard-of-care protocol for documenting domestic violence cases. The program is now being expanded to other Columbia branch facilities throughout the south Florida region.
Does cost savings and potential risk of liability play a role in Columbia's use of photo documentation? "I don't know any organization or facility that doesn't want to be as cost-effective as possible," Nolan responds. To her and Emergency Department personnel like her, related cost benefits are purely secondary.
"We started taking photos of domestic violence victims because we wanted to do more for our patients than just document their injuries in words -- because words alone don't always do justice. And we do know," Nolan adds, "that a lot of our patients like the fact that we take photographs and the photographs are held here."
By all logic and in no uncertain terms, instant photos and detailed written documentation benefit any health organization for a variety of reasons -- some of which are cost-related. But at the end of a 12-hour shift, effective documentation for the sake of saving lives is the ultimate mission for Nola, Famularo, McGrogan, Laverde and thousands of front-line medical personnel and program administrators who, day in and day out, continue to ask the question, take the picture and try to break the cycle of domestic violence.
References
Ellen Taliaferro is a faculty and attending emergency physician at Parkland Health and Hospital System in Dallas, Tex., and co-founder of Physicians for a Violence-Free Society, an effort dedicated to stopping the cycle of violence through education. (214/638-4200)
A. Morgan Baker is a freelance writer based in Southern California.