BACKGROUND: The barriers physicians face when providing care to victims of domestic violence are well detailed in the literature, but few studies provide insight into how physicians overcome these barriers. Our goal was to describe the domestic violence interventions used by physicians who are committed to providing quality health care to battered women.
METHODS: We conducted 6 focus groups with 45 San Francisco Bay Area physicians who had intervened with victims of domestic violence. The sessions were audiotaped and transcribed. We constructed, through constant comparison, a template of open codes to identify themes that emerged from the data.
RESULTS: Our analysis revealed that physicians viewed validation (ie, providing messages to the patients that they are worth caring about) as the foundation of intervention. Other interventions included labeling the abuse as abuse; listening and being nonjudgmental; documenting, referring, and safety planning; using a team approach; and prioritizing domestic violence in the health care environment. Physicians described a range of rewards for intervening with victims, from seeing a patient change her entire life to subtle shifts in the way a woman thinks of her relationship and herself.
CONCLUSIONS: Our study offers insight into how physicians can intervene to help victims of domestic violence. Recent interview and survey studies of battered women support the physician interventions described.
In response to the public health consequences of domestic violence and the number of battered women whom physicians see in their practices,1-4 medical organizations including the American Medical Association and the American College of Obstetricians and Gynecologists have called for physicians to act as agents of change in abused women’s lives.5,6 In the late 1980s and early 1990s these organizations and others issued guidelines and mandates based on information from domestic violence experts that outlined how physicians should intervene.6-8 Unfortunately, these recommendations are not specific enough and do not seem to have improved their responses to violence against women9-11; many physicians are simply not asking women about violence,12-17 and women whose health problems result from abuse are not receiving the health care they need.9,10,18-20
Physicians cite many barriers to intervening with victims, including patient evasiveness and failure to disclose information, lack of time and support resources, lack of education or training, fear of offending the patient, inability to “fix it,” and frustration with lack of change in the patient’s situation or the patient’s unresponsiveness to advice.16,18,21-28 Primary care physicians in the qualitative study by Sugg and Inui28 characterized talking about domestic violence with patients as opening Pandora’s box and associated the act of even asking about domestic violence with unleashing their own fears and discomforts.
Despite the barriers, some physicians are committed to addressing the underlying health problems of abused women. How do these physicians intervene, and what motivates them to continue in their commitment? In previous work,16 we described how physicians with expertise in domestic violence identify victims. With this study we explored how physicians with experience in identifying victims tried to help.
Methods
Participants
Qualitative research commonly uses purposive sampling, a method in which the participants best suited to provide a full description of the research topic are intentionally selected. We sought a sample of physicians in the San Francisco Bay Area who had experience in identifying and intervening with victims of domestic violence. To identify important common patterns that cut across different settings29,30 physicians from 3 medical specialties were sought: primary care (family practice and general internal medicine), obstetrics and gynecology, and emergency medicine.
We conducted our recruitment in consultation with a professional survey research organization. Thirteen physicians known to have domestic violence experience, and additional physicians selected from the yellow pages, were screened and asked to participate in a study exploring the most effective ways for the health care system to meet the needs of victims of domestic violence. Eligible participants were asked to identify other colleagues who are concerned about and treated victims of domestic violence, and these individuals were screened and asked to participate and to identify others. Physicians were eligible if they worked directly with patients 20 or more hours per week, had identified and intervened with victims of domestic violence, and were somewhat confident or very confident about addressing domestic violence issues with patients.
Recruitment ceased when the goal of 12 to 22 physicians in each medical specialty who had the relevant domestic violence experience was reached.
Focus Group Method and Data Collection
In comparison with survey or one-on-one interview formats, the focus group approach allows for a more extensive exploration of the area under discussion. Participants can collectively explore different experiences and perspectives, generate ideas, and debate and compare their ideas with those of others in the group.31 Six focus groups ranging in size from 6 to 11 individuals were conducted during a 3-week period in January and February 1998. Each group was facilitated by 2 moderators who were members of the research team. The sessions lasted approximately 90 minutes and were held in professional focus group settings that allowed hidden viewing. Several researchers viewed the groups from behind 2-way mirrors and completed field notes that were later compared with the observations of the moderators. Before each focus group session written informed consent was obtained from all participants and a written background survey was administered to gather demographic and practice information. Participants received a small stipend for participating. Study procedures were approved by the University of California San Francisco Committee on Human Research.