Should doctors be more proactive as advocates for victims of violence?

Duties of psychiatrists: treat the patient or protect the public?

In this paper I will be discussing the professional duties of psychiatrists. I will argue that there is an ethical tension at the heart of psychiatric practice – between the psychiatrist's professional duties to his or her patient, and what professional duties there might be to protect public safety. It may be of some comfort to clinicians to know that this tension has exercised the best minds for centuries, including thinkers such as Marcus Aurelius nearly 800 years ago (Spruit, 1998).

Alcohol-related violence and the role of oral and maxillofacial surgeons in multi-agency prevention

The maxillofacial region is by far the most frequently selected target in assaults on adults. There is a causal link between alcohol intoxication and injury. Therefore, oral and maxillofacial surgery is, in effect, the lead speciality for those injured in violence and has a responsibility to orchestrate holistic care that takes into account mental health needs. Recent years have also seen a determined effort by oral and maxillofacial surgeons to get involved in wider issues of prevention, exemplified by the national UK BAOMS Facial Injuries Awareness Week. Multi-agency prevention, not just with mental health professionals in the case of individual patients, but also with emergency medicine, public health, local government, the police and the voluntary sector is key to success. Given the potential complexity of collaborations like this, it is important to understand what works in multi-agency prevention. This paper reviews successful interventions: their rationale and how oral and maxillofacial surgeons can contribute to local injury prevention.

Acceptability of asking patients about violence in accident and emergency

OBJECTIVES

To assess the acceptability to patients attending accident and emergency (A&E) of routine questioning about violence.

METHODS

A questionnaire survey (15 questions; 5 point Likert scale) was distributed to a representative sample of all adult patients attending a district general hospital A&E department, Lancashire, England over a seven day period.

RESULTS

303 questionnaires were distributed and 281 returned questionnaires were available for analysis. Some 67% (95%CI 60% to 74%) of patients agreed that people attending A&E should routinely be asked about whether they have been assaulted. Altogether 89% (95%CI 85% to 93%) thought that health care staff should encourage victims of abuse or violence to inform the police, while 74% (95%CI 68% to 80%) thought that health care staff should routinely inform the police. While only 45% (95%CI 36% to 54%) of patients thought that people who had been assaulted would be likely to tell if asked, 81% (95%CI 76% to 86%) thought that if they themselves were victims they would tell if asked directly.

CONCLUSIONS

Patients attending A&E departments support routine questioning by doctors and nurses about violence. They also support health professionals routinely informing the police in cases of violence. Further research is required into the outcomes of routine and direct questioning in A&E of patients about their exposure to violence.

Emergency medicine and police collaboration to prevent community violence

An important responsibility of emergency departments is the management of injuries sustained in assaults. Most assaults, including many causing serious injury, are not reported and not recorded by the police. This is important because police investigation and the conviction of offenders has a substantial deterrent effect and because information about the circumstances of intentional injury is key to prevention. Recent investigation of ED-police collaboration has shown that many of the injured, and ED staff want offenses to be reported but that there are attitudinal, logistic, and ethical-legal obstacles to achieving this. Organized joint efforts by emergency medicine personnel and police departments, on the basis of a sound legal and ethical framework to protect the rights of both victims and offenders, should deter more violent offenders and would-be violent offenders. They also provide the police with unique aggregate, nonconfidential information that is of substantial help in tackling violence. ED data can be used to measure and refine violence prevention initiatives and are being developed as the basis of a new, independent measure of police performance. Strategies, practical ideas to overcome obstacles, and directions for future research are suggested.

Mandatory reporting of intimate partner violence to police: views of physicians in California

OBJECTIVES

This study examined physicians' perspectives on mandatory reporting of intimate partner violence to police.

METHODS

We surveyed a stratified random sample of California physicians practicing emergency, family, and internal medicine and obstetrics/gynecology.

RESULTS

An estimated 59% of California primary care and emergency physicians (n = 508, 71% response rate) reported that they might not comply with the reporting law if a patient objects. Primary care physicians reported lower compliance. Most physicians agreed that the legislation has potential risks, raises ethical concerns, and may provide benefits.

CONCLUSIONS

Physicians' stated noncompliance and perceived negative consequences raise the possibility that California's mandatory reporting law is problematic and ineffective.

Outcome evaluation of an emergency department protocol of care on partner abuse

STUDY OBJECTIVE

To evaluate the impact of a protocol on partner abuse (PA) at increasing identification and improving acute management of abused women by emergency department (ED) staff.

METHODS

A community intervention trial compared two public hospital EDs at baseline and following implementation of a PA intervention. The intervention involved training staff at one ED in a protocol for the identification and acute management of abused women. Outcomes were assessed by reviewing a random sample of women's medical records. Identification of PA was assessed for each record on a yes/no basis. Identified cases were classified as 'confirmed' or 'suspected' PA. Acute management was assessed by ascertaining staff documentation of abuse and use of interventions.

RESULTS

Approximately equal numbers of records were reviewed at each ED, pre and post implementation (total n = 8,051). Eighty-nine per cent of ED staff were trained. No difference in the overall identification of PA was found (chi 2 = 0.13, p = 0.72), but logistic regression analyses showed other significant changes. At the intervention site, there was an increase in confirmed cases of PA (chi 2 = 7.6, p = 0.006), a trend towards increased documentation (chi 2 = 3.5, p = 0.06) and a significant increase in interventions offered (chi 2 = 13.8, p = 0.002). Changes at the comparison site failed to reach significance.

CONCLUSION

Implementation of this protocol resulted in a moderate increase in confirmed cases of abuse and improved the acute management offered to identified victims. The findings reinforce recommendations for widespread implementation of training and protocols to address partner abuse.

Vulnerability, victims and violence

The burden on accident and emergency (A&E) departments of dealing with the aftermath of violence has increased substantially in the last 10 years. Both the underlying causes and the effects on the injured are multifaceted. It is important that clinicians who treat the injured know which interventions, like early family support and preschool education, are effective in preventing violence. It is also important to target those who will benefit from interventions to prevent, for example, serious psychological sequelae or further alcohol related harm. As with child protection, the organisation of services for adults needs to be built on teamwork with other agencies, particularly so that the injured are assessed for risk of future harm and are given opportunities to report offences to the police if they wish. Up to now, the contribution of A&E doctors to dealing with violence has been largely reactive. This policy paper argues that since many of the underlying causes and circumstances of violence can be modified, a more proactive, interagency approach would be effective in the fight against violence.

Violence: the relation between seriousness of injury and outcome in the criminal justice system

OBJECTIVE

To investigate the relation between injury severity in assault, offence seriousness, and outcome in the criminal justice system.

METHODS

Prospective random sample of 93 assault victims who attended hospital were interviewed and examined and followed through the criminal justice system. Patient and police interviews were carried out at Bristol Royal Infirmary accident and emergency and outpatient departments, wards, and in Avon police stations and criminal courts. Severity of injury (injury severity score [ISS] assessed by the major trauma outcome study group), offence seriousness (Delphi panel of criminologists), and outcome in the criminal justice system were recorded.

RESULTS

Median ISS was 4 (range 1-17). There was no significant correlation between ISS and outcome in the CJS (rs = 0.07). There was a weak correlation between offence seriousness and outcome (rs = -0.24, P = 0.019).

CONCLUSIONS

Outcome in the criminal justice system was not predictable from injury severity scores and was only weakly linked to offence seriousness. Contacts with medical services are opportunities for protecting those at risk of violence.