Healthcare providers reported to be failing to spot abuse

A sad story in the Observer (11 Nov) reports that healthcare providers are ‘failing to spot child abuse’:

Doctors and social workers are failing children who end up in hospital after abuse or neglect by their parents, a government-funded inquiry has found. Some are discharged from casualty departments and allowed to go home, despite suspicious injuries such as a black eye or broken arm, because they are not identified as being at risk, states a report by the National Children’s Bureau (NCB) charity.

Doctors and nurses say specialist social workers are overworked and often reluctant to intervene, even if it is thought children are likely to suffer further harm. Social workers, for their part, told researchers they were ‘frustrated with medical staff who were not prepared to make a decision about whether a child’s injury was accidental or not’ because they did not want to be the one that ‘labelled’ a family as abusive.

Earlier this month a new study in the Annals of Internal Medicine reported that in the US physicians and nurses “typically asked [women reporting to emergency departments] about domestic violence in a perfunctory manner”.

Although so often the emergency room is the first time that abuse – of intimate partners or of children – comes to the attention of the authorities, it seems that healthcare providers are poorly equipped to notice and to deal with it.


Abstract below the fold.


Background: Women who are victims of domestic violence frequently seek care in an emergency department. However, it is challenging to hold sensitive conversations in this environment.

Objective: To describe communication about domestic violence between emergency providers and female patients.

Design: Analysis of audiotapes made during a randomized, controlled trial of computerized screening for domestic violence.

Setting: 2 socioeconomically diverse emergency departments: one urban and academic, the other suburban and community-based.

Participants: 1281 English-speaking women age 16 to 69 years and 80 providers (30 attending physicians, 46 residents, and 4 nurse practitioners).

Results: 871 audiotapes, including 293 that included provider screening for domestic violence, were analyzed. Providers typically asked about domestic violence in a perfunctory manner during the social history. Provider communication behaviors associated with women disclosing abuse included probing (defined as asking 1 additional topically related question), providing open-ended opportunities to talk, and being generally responsive to patient clues (any mention of a psychosocial issue). Chart documentation of domestic violence was present in one third of cases.

Limitations: Nonverbal communication was not examined. Providers were aware that they were being audiotaped and may have tried to perform their best.

Conclusion: Although hectic clinical environments present many obstacles to meaningful discussions about domestic violence, several provider communication behaviors seemed to facilitate patient disclosure of experiences with abuse. Illustrative examples highlight common pitfalls and exemplary practices in screening for abuse and response to disclosures of abuse.