It's not often that I find myself using the words "computer survey" and "domestic violence" in the same sentence. The former seems impersonal and cold, the latter emotional, bad and deeply personal.
Yet a new study, conducted in Toronto and published in last month's Annals of Internal Medicine, found that when patients started their appointment with a visit to a touch-screen computer, family doctors were able to double their ability to uncover violence and controlling behaviour by intimate partners.
Domestic violence is a private matter. The vast majority of it happens behind closed doors or in the intimate personal language of couples. In clinics, we treat the sequelae of physical or sexual violence, but control is the root problem, and intimidation is the tool of choice for gaining control.
"Intimate partner violence and control," or IPVC, is the more accurate name now given to domestic violence, which was virtually unrecognized as a health-care issue until three decades ago. Now it is part of the medical lexicon.
Yet one shift in the emergency department or a week in a family doctor's office will reveal that we still largely fail suffering patients.
All day, every day, in busy clinics, violence and control manifest themselves not just in injuries, but in negative consequences from the denial of basic needs such as shelter and food, or from having to be an observer of family violence (as thousands of children are each year in Canada).
The numbers are staggering: U.S. data reveal that, regardless of the initial complaint, 22 to 35 per cent of women presenting at emergency departments are there for problems related to domestic violence. One in three female trauma patients is a victim of abuse. Women are more likely to be assaulted, injured, raped or killed by a current or previous male partner than by assailants of all other categories combined.
(Although less common, violence can also be from women to men. Studies have shown that 12 per cent of murdered men are killed by their wives or girlfriends.)
The situation is similar in Canada. A 2006 review in the Journal of the American Medical Association showed Canadian rates of partner violence recorded at hospital emergency departments were about 18 per cent, and in family practices 8 per cent. The first step - of many - for someone suffering under violence and control is recognition.
While longitudinal studies show that we can raise patients' sense of self-worth through tailored counselling services, and also reduce their isolation and their partners' controlling behaviour and physical violence, clinical diagnosis often does not change things.
Medical students I work with sometimes look upon a person experiencing IPVC in absolute frustration, saying they seem unwilling to "help themselves."
The victim's reality can be very different. Many suffer silently because when they do the personal math of kids, finances, shelter, their own mental health, culture and future implications, the best equation for them at the time is the status quo.
So the findings of this new study are intriguing and encouraging. The researchers, led by Farah Ahmad, randomly divided patients at a family practice unit at St. Michael's Hospital in Toronto.
Half received typical care and half were directed first to a computer survey, which asked them a wide range of questions about mental health, addiction and family violence. The survey took, on average, seven minutes to complete. The study involved 283 women over 18 years of age in a current or recent intimate relationship.
Computer screening doubled the opportunities for detecting and discussing domestic violence in those at increased risk for or actually suffering from it: 18 per cent in the group who used the touch screen, compared with 9 per cent in the control group. And I suspect the 9-per-cent pick-up rate was higher than average, because the clinic where the study was conducted is a teaching centre.
So, why does an impersonal computer aid the diagnosis of something so insidious and personal?
My theory is twofold.
First, the fact that a computer is impersonal is why it works. Impersonal equals non-judgmental. When clinicians ask leading questions such as "how are arguments settled in your home?" patients feel under the microscope and tend not to divulge. Second, like most successful e-health applications, this intervention uses technology to augment the caregiver-patient relationship rather than replace it.
The Commonwealth Fund National Survey has identified that 92 per cent of women who are physically abused by their partners do not discuss these incidents with their doctors. We assume there is no problem, and patients assume there is no way out.
Well, they say assumptions are the termites of relationships, but - in this small trial, at least - a simple computer survey overcame assumptions and illuminated one way forward.
This dark corner of medicine and society needs all the illumination it can get.
Dr. Michael Evans is an associate professor and physician at the University of Toronto, where he is leading both the Health Media Lab at the Li Ka Shing Knowledge Institute of St. Michael's Hospital and Patient Self-Management at the Centre for Effective Practice in Family & Community Medicine.
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