We used a semistructured guide that allowed the facilitators to follow certain topics and open new lines of inquiry when appropriate.32 Open-ended questions were formulated based on our previous interviews with survivors of domestic violence33 and a review of the literature ( Table 1 ). Audiotapes of the focus group sessions were transcribed by research staff; the principal investigator reviewed these transcripts for accuracy.
Coding and Analysis
For initial analysis we conducted multiple readings of transcripts to identify prominent themes. The investigators independently reviewed the transcripts and then met to review and discuss differences of opinion about interpretations and to further refine themes driven by the words and phrases of the participants. Through this process and the constant comparison of new data against emerging themes, a template of open codes was constructed. The transcripts were coded and specific themes within the narratives of the participants were identified in accordance with standard qualitative analytic convention.34 Coded data were organized using NUD*IST 4.0 software (Qualitative Solutions and Research; Victoria, Australia). This software helps ensure the consistency of study findings and creates an audit trail.35 The data were interpreted in the context of the original focus group sessions and the current literature. The final coding scheme and analysis of the findings were reviewed, and disagreements were discussed by the team until consensus was reached.
To further enhance the credibility of the findings, a qualitative technique called member check was used.36 Results were directed back to 3 research participants to confirm that their experiences and those of other participants in their focus group were reflected in the findings.
Results
Of the 80 physicians who were screened, 53 were eligible, and 45 were able to attend the focus group sessions. Their characteristics are presented in Table 2 . The participants reported that they had identified an average of 28 patients per year as having been physically abused by an intimate partner, and they thought they had helped approximately 60% of those patients.
Helpful Intervention Techniques
Even these physicians reported sometimes feeling overwhelmed, frustrated, and incompetent regarding their role in domestic violence cases. They believed, however, that addressing partner abuse was part of their job and reported various ways that they have tried to help battered women improve their situation and their health. Our data analyses revealed that the following themes were common across specialties.
Give Validating Messages. The most common aspect of intervention was validation. Whatever their approach to helping, these physicians gave compassionate messages that validated the woman’s worth as a human being and indicated that the abuse was undeserved. One participant put it this way: “Just my being there, caring about them consistently, giving another message [helped]: You are worth caring about, you are deserving, you are valuable.” Physicians tended to embed this kind of attitude and message into their interventions with abused patients, making validation the foundation of their interactions with them.
Break Through Denial and Plant Seeds for Change. Physicians reported that within the context of a trusting relationship they tried to break through the denial these women presented about the seriousness of their experiences. Some physicians reported labeling the abuse for what it is, blatantly wrong and criminal. They believed that over time they could help victims to begin to see this reality and change their situation. One participant said:
I let them know that what’s going on is outlandishly not right, that they don’t deserve to have that happen. It’s frankly illegal, and you can bring charges against someone for doing that. Sometimes people can be shocked by finding out that that’s the case. You can plant a seed about their self-esteem … and their ability over time to change that situation, but piecemeal.
Another physician reported showing women the photographs taken of past injuries to remind them of the partner’s pattern of abusive behavior: “We begin every session with: Do you remember that? Sometimes the reaction is: No, it didn’t happen that way. But the photograph just sits there.”
Listen Nonjudgmentally. Physicians described listening and attending to the whole person as central to providing good health care to all patients, especially victims of abuse. In the context of listening they reported on the need to maintain a healing attitude by banishing criticism, blame, and judgment, but agreed that achieving this was difficult and required letting go of the desire to fix it by treating the women as competent adults. One participant said:
I try to get across just from my tone of voice primarily, that I’m not judging them. Because I made that mistake quite a while ago—my judgment was right away: Well, this is terrible; you’ve got to get out. And I could watch the person psychologically fly away from me. So in order to maintain that [trusting] space, that connection with them, it’s really important for me to get clear that I’m going to listen and not judge them. And it’s all going to change on their time.