“You're Not a Victim of Domestic Violence, Are You?” Provider–Patient Communication about Domestic Violence

BACKGROUND: Women who are victims of domestic violence frequently seek care in an emergency department. However, it is challenging to hold sensitive conversations in this environment. OBJECTIVE: To describe communication about domestic violence between emergency providers and female patients. DESIGN: Analysis of audiotapes made during a randomized, controlled trial of computerized screening for domestic violence. SETTING: 2 socioeconomically diverse emergency departments: one urban and academic, the other suburban and community-based. PARTICIPANTS: 1281 English-speaking women age 16 to 69 years and 80 providers (30 attending physicians, 46 residents, and 4 nurse practitioners). RESULTS: 871 audiotapes, including 293 that included provider screening for domestic violence, were analyzed. Providers typically asked about domestic violence in a perfunctory manner during the social history. Provider communication behaviors associated with women disclosing abuse included probing (defined as asking > or =1 additional topically related question), providing open-ended opportunities to talk, and being generally responsive to patient clues (any mention of a psychosocial issue). Chart documentation of domestic violence was present in one third of cases. LIMITATIONS: Nonverbal communication was not examined. Providers were aware that they were being audiotaped and may have tried to perform their best. CONCLUSION: Although hectic clinical environments present many obstacles to meaningful discussions about domestic violence, several provider communication behaviors seemed to facilitate patient disclosure of experiences with abuse. Illustrative examples highlight common pitfalls and exemplary practices in screening for abuse and response to disclosures of abuse.