Welcome to episode number 1 of the Halt, Help, Heal from domestic violence podcast. This podcast is from SAATHI of Rochester, a nonprofit organization for helping South Asian victims of domestic violence. I am Deepthi Rao your host. Today, we are going to talk about the role of doctors and medical professionals in the fight against domestic violence.

Halt, help and heal from domestic violence is a podcast where we will be talking about issues related to domestic violence and adverse childhood experiences. 

[Deepthi] 

Welcome Welcome,Welcome.

A warm welcome to all of you listening to the show. 

Today I’m joined by my co-host, Dr. Shashi Sharma, a senior obstetrician gynecologist, who recently closed her practice as she is at high risk for COVID. 

Dr. Sharma is the founder and is also the current president of Saathi of Rochester. Saathi is a nonprofit organization that helps South Asian victims of domestic violence residing in Monroe and surrounding counties. 

[Deepthi] 

 Dr. Sharma, back in 1995. I was in a single car crash. The car was totaled, and I was taken by ambulance to the emergency room. After the ran a number of tests, a doctor stopped by to check me and asked me in private, “Are you facing any domestic abuse at home?”

I burst out laughing, thinking what is totaling my car, being groggy has to do with this line of thinking and questioning about domestic violence. 

I still remember this disconnected questioning that happened 25 years ago. 

So, Dr. Sharma, why do you think the doctor asked me about domestic abuse in that scenario?

[Dr.Sharma]  

Well, Deepthi the short and correct answer is because medically speaking, that was the right thing to do. 

However, the longer more informative and educational answer is that since the VAWA Act was passed in 1994, everybody working in the medical, legal and law enforcement fields, is mandated to be fully trained in all aspects of domestic violence. As a result, these individuals, when connected with the domestic violence victims, are well aware of the adverse effects of trauma and burden of challenges from domestic violence these victims have to face. 

In fact, students are taught in medical school how to screen every patient for domestic violence, and how to look for adverse effects of domestic abuse on the health of the victims. 

Thus, all the healthcare providers after finishing with their questioning pertaining to the reason for the visit of the day, are they expected to ask this last question in privacy and say gently  “One question I routinely ask every patient is are you experiencing any abuse at home or by someone? Are you?”

So Deepthi your astute doctor asked you about the abuse only as a routine and to make sure your grogginess and totaling your car was not from insomnia caused by stress of domestic violence that you may be experiencing. 

As a matter of fact, it is interesting that your domestic violence questioning in emergency room occurred just a year after the VAWA Act was passed in 1994. So your doctor must have learned only recently to routinely ask every patient about domestic abuse. So, your astute doctor practiced what he has recently learned. 

However, being unaware of the 1994 VAWA law, it appeared as a disconnected questioning to you. 

Now, let’s go a bit further. Had you answered yes to the doctor, he would have called the hospital social worker to talk to you in depth about your abuse situation, assessed your safety and made appropriate plans and needed referrals for you.

So Deepthi, this is the long answer to your surprise from a routine domestic violence question asked after your emergency room visit following a motor vehicle accident.

[Deepthi]  

Oh, so I when I was in the emergency, I was not aware of this 1994 act that was passed. 

So from what you just said, this doctor was very meticulous. What I am thinking of is about those busy doctors who are in a time crunch to complete follow up visits in the 15 minutes time slot allotted for each patient. So do you think these busy doctors may skip asking about DV as it can take time and delay the next appointments? What would you do Dr. Sharma?

[Dr. Sharma]  

You are so right Deepthi. The busy doctors may skip the screening to avoid domestic violence in the short 15 minutes visit. This is to avoid getting late for the next patient who may have to wait and possibly get stressed. Still, every doctor must do the domestic violence screening at least once a year. The annual health checkup is a good time to do this screening. As these visits are kept for a longer time.

I strongly suggest all the physicians to have the posters of the domestic violence shelters and counseling services placed prominently on the walls. Also, keeping the contact cards in the bathroom and exam rooms enables the patients to take them when no one is looking. 

Finally Deepthi you want to know what I will do? 

Truly speaking, I screen every patient routinely on their arrival for depression, anxiety, post traumatic stress and mood disorder. If a patient screens positive for any of these, I get alerted even before I start the visit. 

Truly speaking, all the victims of domestic violence have some extent of depression, anxiety, post traumatic stress and mood disorder from enduring the stress of domestic violence. These screen positive patients I observe more carefully. 

Let us say for example, I am seeing a screen positive patient and I find her to be very nervous and anxious during the visit. So after completing her visit, I will gently ask her “What is upsetting you? Why are you so nervous?”

If she opens up and says for example. “My husband is very abusive. Last night he was choking me in front of my three year old daughter who was crying and watching me scream and struggled to escape.” On my further questioning. She says she did not lose consciousness and had no bleeding or visible injury. I will then make sure her examination shows no abnormality. 

Still, choking is a big challenge. It requires right skills and right actions but you have no time. So now I will quickly tell her it is serious as choking can be fatal. She deserves better. Her safety is an urgent priority and it is best to immediately directly connect her with an advocate from Willow the local domestic violence shelter. I will sit her in a room with the door closed to talk to the advocate by phone and discuss all her issues, especially the previous night’s choking incident and do full safety planning.

I will remind her to always remember 911 in case of emergency and to stay connected for follow up counseling with the Willow’s advocate, via the phone number of Willow which is 585 (our area code) two two two SAFE 585-222-7233. 

So Deepthi, the most important goal in dealing domestic violence is to make sure that no victim remains unrecognized after a doctor’s visit. And if a victim is facing danger, she’s immediately connected with an advocate from the domestic violence shelter, even in the brief visit.

[Deepthi]  

So Dr. Sharma, in the previous scenario, you were talking about choking and looking for signs, but at the doctor’s visit, visible injuries to face or head are the strongest indicators of violence. How about those invisible injuries or subtle signs or findings of choking that are not obviously seen?

[Dr. Sharma]  

You are right Deepthi. Physical violence is obvious. When you see a black eye, a broken nose or bruises all over even if the victim says I fell, only to say what her abuser had asked her to say. 

The doctors must examine every trauma patient fully and order tests as indicated by the exam. For example, pain in hands could be from being hit, causing a finger sprain, or even fracture of the hand bones, especially the bones in the palm. One below the pinky may break as the hand is used in self defense. Here, only X-Ray of the hands will reveal fracture of the fifth metacarpal bone. Obviously, an invisible injury on arrival. 

Similarly, fresh bruises are difficult to see in dark skinned individuals, even when using special lights. These special lights do help to visualize early bruising in fair and white skin individuals. 

A full body exam with the patient undressed may reveal additional bruises on the front and back of the body and arms and thighs, as these areas are normally covered when one is fully dressed. 

In cases of choking, some bruising may be seen in the neck with some tenderness on examination, and the patient may complain of hoarseness in the voice or pain on talking and swallowing from possible injury to the voice box. 

But in severe choking with loss of consciousness and pain in the neck, there may be more serious injuries. And these patients need to be sent to urgent care for full evaluation, special testing with CAT scan, MRI and getting consults with neurology, ENT and orthopedic as indicated. 

The additional important and profound invisible injuries in domestic violence victims are caused by the emotional, psychological and mental abuse that leads to profound adverse effect on general and mental health of these victims. These require intense counseling and therapy for healing.

[Deepthi]  

So Dr. Sharma, you have documented the physical injuries and put the diagnosis of domestic violence for billing, and the patient says her partner will be infuriated by saying domestic violence diagnosis and she’s afraid the abuse will escalate. What will you do in such a scenario?

[Dr. Sharma]  

This is surely very tricky. I will inform her that the examination and findings of injuries are documented in the medical record. All her medical record information remains confidential. Any request for a copy of her medical record must accompany her signed, dated and valid consent that is mandatory before any information is released to anyone. She is thus reassured her medical information and record release is under her full control.

For fulfilling the request of not to use the diagnosis of domestic violence for billing the office visit, I will use depression and anxiety for diagnosis on the bill that the partner will see and not get upset and escalate the abuse. 

However, the domestic violence diagnosis will remain in the medical record, along with depression, anxiety, post traumatic stress, mood disorder derived from the mood questionnaire, she had completed herself on arrival.

[Deepthi]  

So you mentioned mood questionnaire. What happens if the doctor after reviewing the completed mood questionnaire asks directly about domestic violence and surprisingly, the patient answers “Yes, there is violence in my home and I don’t feel safe.” What could the doctor do now?

[Dr. Sharma]  

Deepthi This is a real serious safety issue now. It needs further evaluation, counseling, planning and making appropriate reference before the patient leaves the doctor’s office. 

Let us say for example, the day the doctor asks her gently about why she feels unsafe at home. And she answers, “My husband has anger issues. He is verbally and emotionally abusive. I tolerate all for the sake of my kids to keep my home intact for them. I remember I was heartbroken when my parents divorced. And I lost my home. I recall as a little girl packing and going from place to place. So I had decided I will never let this happen for my kids. But last week, we had some arguments. He got into rage and sexually abused me. I could not even sit for two days from the pain. I just want him to stop his verbal, emotional and now the sexual abuse.”

Deepthi in this situation, first, a careful examination is needed. And if the examination reveals everything is normal, the doctor will advise her that she’s a good mother, trying to keep her own home intact for the kids and enduring the escalating domestic abuse. But domestic abuse is bad for her and her kids health. 

She must be informed that it is not good for kids to grow in the toxic environment. And for kids to face lifetime adverse effects of trauma from adverse childhood experiences. After discussing the risk, benefits of staying in this worsening abusive relationship and having adverse effects of domestic abuse on herself and kids; I would suggest she

 get counseling from Resolve for herself,

 get counseling arranged from Tree of hope for her husband and then couples counseling later if appropriate,

 and must go to Bivona for kids to heal from adverse childhood experiences. 

Most important is to make sure that before the patient leaves the office, she has connected with an advocate from the domestic violence shelter ‘Willow’ in Rochester, for her safety planning and dealing with the domestic violence issues.

[Deepthi]  

Are there any guidelines or forms to screen for domestic violence that are recommended by AMA? Do you suggest an easy tool that physicians can use to screen for domestic violence? What informational resources do you recommend?

[Dr. Sharma]  

Good question Deepthi. The American Medical Association AMA, in 1992 put together a series of 10 questions for screening for domestic violence. 

Then, someone came up with HITS as another quick tool with four questions to screen for domestic violence – standing for have you been Hurt, Insulted, Threatened or Screamed and cursed by anyone? And if even one answer is yes, she is positive for domestic abuse. 

Again, Deepthi. every physician is trained to screen every patient about domestic violence at least once a year, and most likely at the annual health checkup when there is some extra time. 

Personally, I find RADAR as the user friendly, complete and a quick working tool. 

R stands for routinely screening for domestic abuse

A stands for asking directly, non judgmentally, kindly alone and apart from the partner 

D for documenting your findings, 

A for assessing the safety of the client and 

R for reviewing the options and providing the necessary reference. 

Now to assess the patient safety, there are six questions. 

1. Are you afraid to go home? 
2. Have there been any threats of homicide or suicide? 
3. Are there weapons in the house like guns and pistols? 
4. Can you stay with family or friends in case you have to leave the home in a hurry?
5. Do you need access to a shelter? 
6. Do you want police intervention? 

if safety is at risk, patient is immediately connected with the advocate from the local domestic violence shelter for safety planning, and her future needs to be addressed. 

Now for the additional resources for further information about domestic violence. Google is a very good friend. You put domestic violence and you will get a ton of information. However, a lot of work has been put out on the websites by Futures Without Violence. Center for Disease Control, National Institute of Health the American College of Obstetrician and Gynecologist, National Resource Center for Domestic Violence, Asian Pacific Islander Institute of Domestic Violence, and VAWnet – violence against women net. 

So if you put any of these on your search engine, you will get all the information that you could possibly use on one visit.

[Deepthi]  

I will definitely make sure that these resources that you mentioned will be available in the show notes. 

So, Dr. Sharma, how can a seed be planted at the doctor’s visit, that there are resources available for domestic violence victim? How would a clinic show its awareness of family violence and its willingness to help

[Dr. Sharma]  

Deepthi I strongly believe ‘what the you see, the mind remembers’ as the visual image gets quickly imprinted in the brain, and the brain recalls it anytime there is a reminder and a trigger. 

So the easy and simple way to plant the seed of domestic violence in doctor’s office is to have posters about domestic violence shelters, counseling services, depression, all placed prominently on the walls of the waiting room, bathroom and exam rooms.

The patient’s glance at these posters while waiting in the waiting room and exam room, and the contact cards about the domestic violence shelters and counselors placed in the bathroom and exam rooms, give the patient an opportunity to take them and hide them in a secure place for future needs. Some victims find an opportunity to call back for more information when they find privacy and feel safe to talk freely.

[Deepthi]  

Your final thoughts on what is the role of a doctor as a community member in our fight against domestic violence and child abuse.

[Dr. Sharma]  

Deepthi It is sad to say that the incidence of domestic violence has remained at 25 to 35% even after the VAWA Act was passed in 1994. And still 85 to 90% of affected individuals are women. 

This ‘shelter in place’ imposed by COVID has added fuel to the fire of domestic violence, as victims have no time away from their abusers, leading to an increase in domestic violence. Shelters have remained open, but with limited staff. 

Doctors have remembered RADAR to screen their patients for domestic violence. But the in-person visits have been replaced by televisits. And that does not suit these homebound domestic violence victims who need privacy to discuss their issues. 

These victims are undergoing unrelenting stress from the increasing domestic abuse from this COVID mandated shelter in place. 

Here is when an astute doctor can connect the cause of failure of medical conditions to improve to be from increased stress of domestic violence. 

When the brain perceives any stress, it responds by releasing neurotransmitters. These neurotransmitters enter the blood and circulate everywhere in the body and affect the organ where they get a strong hold, causing many symptoms. 

For example, in the brain, the stress causes sleep disorder, anxiety, depression, post traumatic stress disorder, headaches. 

In stomach it produces heartburn stomach aches. 

In bowel, it causes bowel cramps and constipation, with or without diarrhea or both. And this is called irritable bowel syndrome. 

In bladder stress causes frequent voiding with difficulty in holding urine and is called nervous bladder. 

In chest you get frequent lung infections, palpitations and racing of heart. 

Immune system gets weak from stress and immune disorders get deteriorated.

Thus, it is obvious that domestic violence causes havoc on victims health. 

Yet, there is hope of recovery from domestic violence by bringing domestic violence to a halt by giving help to heal from deep trauma of domestic violence.

These victims while having counseling and psychotherapy can consider some additional tools to reclaim their mental, emotional and physical health. The additional tools to choose from are like Eye Movement Desensitization and Reprocessing, hypnosis, Neuro Linguistic processing, acupuncture, exercises like Tai Chi, Qigong, meditation, art therapy, music therapy, peace circle.

The children growing in these households with domestic violence must receive counseling as these children are indirect victims experiencing adverse effects on their health, mind and future development from trauma of these adverse childhood experiences. Most important is teaching children early in life, about healthy relationships and how to get help when stressed from witnessing violence at home. Therefore, it is crucial to have school counselors that children can confide in and get timely help to heal and recover from trauma have adverse childhood experiences they are exposed to. 

Lastly, Deepthi everyone must remember that no matter where you are, you can always get help, and the directions to reach the nearest domestic violence shelter by calling the National Domestic Violence Hotline. And that number is 1 800 799 SAFE. Again 1-800-799-7233

[Deepthi]  

Thank you, Dr. Sharma for sharing your thoughts about how a doctor plays a role in combating domestic violence. Our community needs to be engaged in eliminating domestic violence. And having these kinds of conversations is one way for us to be part of the solution. Even the emergency doctor decades ago, was part of the community fighting against domestic violence.

[Dr. Sharma]  

Thank you Deepthi for this educational podcast, very valuable for 25 to 35% of women who are going to benefit from your effort.

The information presented is intended for general educational purposes only. The listener is advised to consult with a licensed physician and or an attorney regarding his or her specific medical legal needs. No physician-patient relationship is created with this podcast. The opinions and ideas expressed are those solely of the presenter, and may not reflect those of other individuals or societies.

This has been the Halt, Help and Heal from domestic violence podcast brought to you by SAATHI of Rochester, a nonprofit organization for helping South Asian victims of domestic violence. We hope you enjoyed this episode. Please be sure to leave a review on iTunes or any other podcast platform. You’re listening to this episode on. If you want to talk more about the topics we discussed today, visit saathiofrochester.org/podcast where you will find the show notes