Have I written about this before? It seems like I must have. I certainly have been bombarded with the idea that doctors should screen their patients for relationship/domestic violence during these last several weeks. And the idea continues to appear no less ill-conceived.
As any good epidemiologist knows, if you are going to screen for some condition, that condition should meet two basic criteria:
1. the condition you are screening for should be asymptomatic
2. intervening earlier should have some effect on the disease process in terms decreasing morbidity and mortality.
There is also the issue of cost-effectiveness which it only makes sense to talk about once criteria 1 and 2 are met. Domestic violence fails to meet the first criteria – it is not asymptomatic. Getting hit, kicked or raped by your partner are all symptoms of domestic violence. By screening for it, we are not using our medical expertise to identify a condition for which we can intervene, thereby helping our patients live longer and healthier. What we are doing is identifying a condition that our patients already know that they have (because the only way we know they have it is by asking them) and then telling them that it’s a problem. Telling patients what is or is not a problem rather than letting them decide for themselves is pretty much the definition of paternalism.
I don’t deny that the prevalence of domestic and relationship violence is huge. Nor that there are thousands of women out there in very bad situations. And I’m glad that there are some resources that these women have available to tap into. But, I don’t believe that there is anything about medical school or residency training that confers the expectation upon doctors that they identify ALL of their patient’s problems and try to solve them. Patient’s may have a whole host of problems which doctors are equally unqualified to deal with. Should we screen our patients for excessive credit card debt? Excessive debt can cause huge emotional distress, bankrupcy and can ruin lives. But, I’ve never heard of any doctors advocating that we should screen for excessive credit card debt. Why is domestic violence different?
Now, if a person comes in complaining that they’re being abused by their domestic partner, I’m more than happy to put her in touch with appropriate resources. But this is not the same as screening. This is a case of the patient having identified a problem and asking for help. And, as a doctor, I will provide whatever help I can. But seeking out patients via screening in whom you try to identify an additional problem? This is fine for conditions like diabetes, hypertension and cervical cancer – conditions for which our medical training has supplied us with privileged information about how much of a problem the condition may or may not be for the patient. But we have no privileged information about how much of a problem the behavior of our patient’s boyfriend is for her. She is much more qualified to make that determination than we are. Therefore, in the final analysis, it simply is not a doctor’s place to screen for domestic violence.
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