BEHIND THE FRACTURES
Hundreds of women come in contact with health practitioners every day, but signs of partner abuse are often missed. Now, the Canadian Orthopedic Association is trying to do its part with a trial program that might become required training for future physi
A trial program aims to train staff at orthopedic clinics to recognize signs of domestic violence — and how to ask patients if they need help. Jason Magder reports in
Do you need help?
The four-word question could make a world of difference to women who suffer in silence from violence perpetrated by their partners. It could even save lives.
But too often, the question is not asked.
Every day in Canada, hundreds of women come in contact with health practitioners who can access resources to get them out of dangerous situations — but signs of domestic violence are often missed.
Now, thanks to a new initiative, the Canadian Orthopedic Association (COA) seeks to do its part to help remedy that problem.
The goal is to train physicians and support staff to recognize the signs and symptoms of intimate partner violence, and teach them how to ask patients whether they need help.
The initiative is dubbed EDUCATE, for Education on Domestic Violence: Understanding Clinicians’ And Traumatologists’ Experiences. It has been implemented on a trial basis in several fracture clinics in Canada and the U.S.
If the study proves fruitful, it could be rolled out as an optional training program for all fracture clinics in the country, and become required training for all future orthopedic surgeons at the residency stage.
Part of the premise is that hospital orthopedic clinics are seen as well-suited to serve as potential safe places for victims of abuse. Unlike chaotic emergency rooms, the clinics see patients several times to follow up on treatment or to remove casts.
A 2013 research paper published in The Lancet — looking at orthopedic clinics in Canada, the U.S, the Netherlands, Denmark and India — found that one in every 50 female patients who visited an orthopedic clinic with a sprain, strain, fracture or dislocation had sustained injuries caused by violence perpetrated by an intimate partner.
Until recently, most orthopedic surgeons and their support staff rarely asked patients whether their injuries were the result of conjugal violence, said Sheila Sprague, a clinical researcher and assistant professor at McMaster University in Hamilton, Ont., and one of the authors of the 2013 study.
While orthopedic surgeons are trained to look for the signs of abuse in children, and are obliged to phone the authorities, that’s not the case with women.
Sprague said most orthopedic surgeons either don’t recognize the signs of violence, or are too afraid to ask.
“I think it’s a combination of not being sure what to do, and the fear of doing the wrong thing,” explained Sprague, who is working with the COA on the trial program.
“If you, for example, call in the police, you can make the situation worse. Telling a woman to leave (an abusive relationship) could make it more dangerous for her.”
Indeed, statistics show that once a woman tries to get out of a violent relationship, the risk to her increases. Women are six times more likely to be killed by an ex-partner than a current one.
But getting help for patients presenting at orthopedic clinics is critically important, because they are at a high risk for the violence to escalate to dangerous levels, Sprague said.
“If they are at the stage where they are being hospitalized due to abuse, the level of risk is definitely increasing,” she said. “Getting them to somewhere safe is of the utmost importance.”
In a recent position paper to its members, the COA urges physicians to be alert for signs of abuse, and to routinely ask patients whether they need help.
“(Intimate partner violence) disclosure is almost never spontaneous,” the paper says.
“In qualitative studies, women have said that being asked about IPV helped them to recognize the problem, break their silence, validate their feelings and instilled in them a desire for change.
“Therefore, the COA encourages its members to educate themselves further about IPV and considers it good medical practice to take steps to identify and offer assistance to its victims.”
Mo Bhandari, a professor of surgery at McMaster, and an orthopedic surgeon, is heading up the COA working group on intimate partner violence.
The goal, he said, is for surgeons across the country to routinely ask about partner violence as part of their general questions to patients — male and female — and to ask every time they see them.
“We think orthopedic surgery is optimally positioned to do something really important here,” Bhandari said.
“When you look at the data, only one out of five women who end up in an emergency room will disclose the violence. That means four out of five will go on through the system without having disclosed the nature of the injury.
“I look at orthopedic surgery as a critical second chance.”
Sprague noted that many women try to hide signs of abuse, so it’s important to ask questions routinely: “Do you need help?” and “How are things at home?”
She said many women will have to be asked several times before they confide they have been abused.
“Women can be very, very good at hiding injuries due to abuse, so I think the program is taking the approach of asking everybody, rather than trying to diagnose it per se, because you may also have a woman who has experienced abuse, but she’s not there because of an injury (from that abuse),” Sprague said.
Besides asking questions, Bhandari said, clinics should make available brochures and put up posters raising awareness about conjugal violence.
When a patient does disclose abuse, he said, it’s important for clinics to have a plan in place to ensure experts who work with victims are called upon to provide help.
“Surgeons are more than happy to identify the problem,” Bhandari said. “But they want to know that their patients will get help fast, and help that is beyond their skill-set as surgeons.”
The COA, based in Montreal, won’t make it mandatory for clinics to take part in the program, but Bhandari said he expects nearly all will come on board once the program
is fine-tuned. “With the overwhelming support we have had for this issue, we don’t anticipate any barriers to rolling this out (nationally) over time,” he said.
Among the first physicians to be trained as part of trial program is Andrew Furey, an associate professor of orthopedic surgery at Memorial University and clinical chief of orthopedic surgery at the Eastern Health Sciences Centre in St. John’s.
He said he was struck and disturbed by research suggesting he likely missed signs of abuse in hundreds of women who have been his patients.
“I used to have a terribly low rate of recognition,” said Furey, explaining that patients would report about once a year that an injury was caused by an intimate partner.
“I don’t think we appreciated in the past what the frequency was. I don’t think it was malice, or neglect, but a large part of it was ignorance of the rate that these incidents occur.”
Armed with the knowledge that abuse is more common than previously thought, most physicians will jump at the chance to be better educated, Furey said.
“This could be the point of entry for hundreds of women per day across the country.”
Bhandari said it should not be up to merely orthopedic surgeons to ask women about abuse, but all health-care practitioners, including physiotherapists and occupational therapists, and family physicians and nurses.
“There are many agencies that will be seeing an injured woman, and I think any of those individuals will be high targets for us,” Bhandari said.
“We are making intimate partner violence everyone’s issue, and particularly orthopedic surgeons’ issue.”
In Montreal, Sylvie Langlais, president of the Regroupement des maisons pour femmes victimes de violence conjugale, welcomes efforts to get more health professionals involved — but noted everyone should be educated to recognize signs of conjugal violence, and offer help when needed.
“These women should not be left all alone,” Langlais said.
“Schools, daycares and hospitals should all be concerned about this.”
Telling a woman to leave (an abusive relationship) could make it more dangerous for her.