Patients’ Advice to Physicians About Intervening in Family Conflict

Dr. Burge's article "Patients’ advice to physicians about intervening in family conflict" resonates strongly with current debate over screening for intimate partner violence. It remains clear that providers continue not to want to talk about issue of intimate partner violence with their patients. I have re-read variations of the first paragraph of this article citing the barriers to screening more often than I care to admit - and it still rings somewhat hollow. I believe that there exists a substantive gap between patient and provider expectations regarding the subject of abuse screening. Other studies have supported the position that patients appear to find screening for intimate partner violence acceptable with the majority welcoming this line of inquiry. Most abused patients often ask little more than to be listened to in a non-judgmental manner, hoping to be advised about how they might be helped with their problems. Two percent of patients sampled in this study felt that providers should never screen for family conflict and six percent did not feel that their primary care provider could be helpful to patients dealing with family conflict. How is it then that we are driven so strongly by minority opinion with 68% of the sample never having been asked about family conflict? Much of the debate over this issue appears to be driven by the social construction of the healthcare management of intimate partner violence. All too often over-burdened providers evoke concerns of fear of the complexity of "Pandora's Box" and the well intentioned "do no harm," as if never asking was not harmful. In fact, the data presented in this study suggests that asking alone may be helpful. Although only one third of the sample reported ever being asked about family conflict and around one tenth were referred for counseling, two-thirds reported their provider's actions to be helpful. Dr. Burge's article reminds us that perpetrators are our patients as well. The healthcare system has unnecessarily and unwisely limited its focus to post-event services for victims with punishment and isolation of perpetrators through the criminal justice system. As a clinician, I have experienced how health-system and community-level constraints have led to patterns of diagnosis, treatment, and health care delivery that do not address the root cause of intimate partner violence - perpetration. If we cannot get providers to ask about intimate partner violence victimization, how can we ever hope to position providers in terms of primary prevention - the engagement of perpetrators? I believe the answer lies challenging the underpinnings of purported barriers to screening. Keys to forward progress include training providers in terms of a health-model of abuse and addressing system-level obstacles to the identification and treatment (referral) of intimate partner violence. The current model of healthcare management of intimate partner violence has left providers with the false impression that a simplified model of identification, support and appropriate referral is inadequate. These data support the notion that patients (the unexposed, the victims and the perpetrators) support intimate partner violence screening efforts and that acceptable interventions include provision of information and referrals. As the authors point out: "These are straightforward skills that are well within the domain of family medicine training." Clearly, more health services research is needed to narrow the gap between patients and providers.

Competing interests:   None declared