A qualitative analysis of how physicians with expertise in domestic violence approach the identification of victims

Background: Physicians have been called upon to identify victims of domestic violence, but few studies provide insight into how physicians can navigate around the barriers to identification. Objective: To describe how physicians who are committed to helping battered patients identify victims of domestic violence in health care encounters. Design: Six focus groups were conducted. Setting: Focus group research facilities. Participants: 45 emergency department, obstetrician/ gynecologist, and primary care physicians in the San Francisco Bay Area who identify and intervene with victims of domestic violence. Measurements: Through constant comparison, a template of open codes was constructed to identify themes that emerged from the data. Data were analyzed according to the conventions of qualitative research. Results: The data revealed five major themes: 1) how physicians framed screening questions to reduce patient discomfort; 2) patient signs that "switched on a light bulb" for physicians to suspect abuse; 3) direct and indirect approaches to identification, with an emphasis on facilitating patient trust and disclosure over time; 4) the rarity of direct patient disclosure; and 5) how physicians redefined successful outcomes of universal screening. Physicians also described two new barriers to screening: mandatory reporting and "burnout" due to lack of direct disclosure. Conclusions: Identifying domestic abuse is difficult even for physicians committed to helping victims. Physician reports illustrate the need to frame questions and develop indirect approaches that foster patient trust. Given the many barriers to screening and the rarity of direct patient disclosure, it may be more productive to redefine the goals of universal screening so that compassionate asking in and of itself constitutes the first step in helping battered patients.