What The Doctor Should Do

By Jill Smolowe

The woman arrived at the New Hampshire emergency room badly bruised, with several cracked ribs. "Someone did this to me. Someone did this to me," she muttered through her pain. The doctor on duty just nodded, then asked if the bandage felt comfortable. He made no attempt to elicit the ugly truth behind her whispers: she'd been battered by her husband.

Such scenes are appallingly common: one-third of all women who arrive at doctors' offices or hospitals seeking emergency treatment, and up to one- quarter of all those seeking prenatal care, are victims of domestic violence. After years of averting their eyes, of treating the symptoms while politely ignoring the causes, doctors are being urged to play a new role. In an unusually strong statement, backed by U.S. Surgeon General Antonia Novello, the American Medical Association last week declared that domestic violence against women is a true epidemic, one that requires response from health officials. According to new A.M.A. guidelines, physicians should routinely screen female patients for incidents of abuse. "Domestic violence is rampant, and doctors are part of the problem," says Novello. "We have to retrain some of us to believe that domestic violence with a fist is as important as violence with a gun."

Horrors on the homefront are the leading source of injury for women between the ages of 15 and 44. Each year 4 million women are severely assaulted by their current or former partner. Many of the victims fail to make it to the hospital in time: more than half of female murder victims are slain by their husband or boyfriend. "For too long, wife battering has been thought of as a private matter," says Sally Goldfarb of the National Organization for Women's Legal Defense and Education Fund. "In fact, it's a public health problem of epidemic proportions."

While the A.M.A.'s statement supports that view, many doctors are reluctant to wade into the domestic thicket. A survey of physicians' attitudes about domestic violence in the current Journal of the American Medical Association reveals their concerns about the ever expanding roles they are expected to assume in modern society and the enormous demands these make on their time. In recent years they have been asked to take a larger role in monitoring child abuse, explaining to very ill patients that they have the right to refuse treatment and screening for depression. "They feel they are being asked to address the entire body and soul of the patient," says internist Nancy Sugg, the study's co-author.

Doctors are also concerned about the legal ramifications of the A.M.A. directive. "If the physician fails to ask and the patient is then further injured or killed, the patient or her survivors could sue the doctor for failing to take action," warns Alan Meisel, director of the Center for Medical Ethics at the University of Pittsburgh. "There is precedent for this in the child-abuse area." On the other hand, while all 50 states require doctors to report instances of child abuse, there is no such requirement for reporting battered spouses. Says Meisel: "A court might well say, 'This is an adult. A doctor is not responsible for protecting her.' "

Doctors are often best situated to identify abuse problems, however uncomfortable that might be. Still, abuse is not always as obvious as a black eye or a broken rib, and victims are often too frightened to reveal the true cause of their injuries. "Abused women often present a very scattered complaint picture that might include depression, sleep disturbance, chronic anxiety, difficulties with mood," says psychologist Angela Browne of the University of Massachusetts, whose research shows that physicians rarely ask patients about violence at home. "They might also have a history of injury. A doctor must try to tie these disparate complaints together."

Physicians should also be on the alert for explanations that don't make sense: a patient may say she fell, but the injuries are on her torso, not her extremities as in most falls; she may say she slipped on an ice cube, not the same ice cube that tripped her up a month earlier. Often women find a partner's authoritarian control more scarring than the physical injuries. Signs of emotional abuse include social isolation and descriptions of intimidation, deprivation or humiliation.

Because physicians are poorly trained to broach so sensitive a subject, they should proceed gently, says Dr. Sugg. Words like "domestic violence" and "abuse" should be avoided. "Women will picture Farrah Fawcett in The Burning Bed and think, 'That's not me, it's not that bad.' " Instead, she recommends that the doctor start very broadly ("How are things at home?") and slowly narrow the field ("Have you ever been hit?," "Are you being hit now?"). The A.M.A. is also distributing waiting-room posters that read, WHEN SOMEONE YOU LOVE STRIKES OUT -- PHYSICALLY, VERBALLY, OR EMOTIONALLY -- TALK TO SOMEONE YOU TRUST.

Alas, doctors who identify victims of abuse cannot write a prescription to cure them. They can only try to determine if the patient can safely return home that day, and provide referrals to social-service agencies and shelters -- and then follow up. But that beats the old approach. "A classic response is, 'Here, take some Valium, go home, chill out,' " says Melissa Eddy of the Texas Council on Family Violence. For battered women, who often feel isolated and utterly worthless, the concern of a high-powered professional and directions to people who can help can make all the difference.

With reporting by Andrew Purvis and Andrea Sachs/New York