Helping doctors open Pandora's box

Sometimes a problem is just too big to get into � like domestic violence. A new Ontario program helps FPs direct patients to the help they need

By Wendy Banks

You've got a full day ahead of you. The waiting room of your family practice is packed with patients old and new with a raft of ailments. You've got a host of other worries on your side � overhead to meet, staff to take care of, your own family to raise.

But first you've got to figure out what's wrong with the stressed-out, headache-plagued, exhausted young pregnant woman in your office � in exactly seven minutes or less. You have a nagging suspicion that your patient's problems have something to do with her live-in boyfriend. You glance at the clock. Five minutes. If she's being abused, what should you do? What are your legal obligations? You rack your brain trying to recall the name of the nearest women's shelter � where is it? Three minutes.

This situation is all too common for family doctors in Canada, according to Dr June Kingston, a GP and former Medical Director of the Sexual Assault/Domestic Violence Services at Trillium Health Centre, in Peel Region, Ontario. Often doctors are hesitant to ask about abuse because they're afraid to open up a Pandora's box of problems that they won't have time to fix. "Every day you see patients with multiple problems, and you're trying to get what you need, direct your patients to the right resources and make them feel supported and cared for, all in a short period of time," says Dr Kingston. "It's really challenging."

Healthcare workers in the Peel Region have decided to do something to help their time-strapped colleagues help their abused patients. The region � which comprises Brampton, Caledon and Mississauga � has taken a block of provincial funding for early childhood development, and devoted it to a new program in which doctors teach other doctors about abuse, their legal obligations and the resources at their disposal.

A year ago, the program was directed mainly at public health nurses, but it became clear that family physicians needed to be brought into the loop, says Susan Harrison, a clinical social worker, public health nurse and the coordinator of the initiative of the program. To that end, they recruited Dr Rosanna Pellizzari and Dr Lopita Banerjee, two local FPs, to devise an outreach plan. The program now consists of one-and three-hour sessions offered to doctors in hospitals throughout the region and taught by a team made up of a social worker, a physician and a representative from Peel Region Health. Participants also receive a kit containing tools for diagnosis and discussion as well as comprehensive information on local resources for abused women. Hours spent in the seminars count towards Mainpro CME credits.

PEER TO PEER ADVICE
The seminar's approach to abuse is based on the Routine Universal Comprehensive Screening model, which is in turn based on the Middlesex London Report of September 2000. One of the recommendations of that report was that all physicians should routinely screen for domestic abuse.

Kathryn Dominey, Clinical Director of sexual assault and domestic violence services at Trillium Health, points out that one of the most useful things about the program is the way it challenges traditional assumptions about abuse. "Many people think that it's only about physical abuse," she says. "But it's a lot easier to see why women stay in abusive relationships when we see the context."

The other main function of the program, according to Ms Dominey, is to encourage doctors to make referrals. "Most physicians will say that the main obstacle to dealing with abuse against women is the lack of time. We want family physicians who don't have the time, to understand that there are people who can help." For example, the Trillium Health Centre, where Ms Dominey works, asks doctors to refer patients to them for the documentation of physical injuries. They also offer followup and counselling services and have access to a local shelter's transitional support worker.

Dr Kingston has been part of the program and agrees that the referral system is very useful for busy FPs. "It's given me all the resources at my fingertips. It's provided me with the knowledge that I have the information here if I need it." She also likes the fact that a physician is involved in presenting the seminars. "Someone who's working in your own field is aware of the pressures, the time constraints, the multiple pulls that you have every day," she says. "I think there are some terrific social workers who are very helpful and supportive, but they don't have quite the same job or the same issues that we have. So if they were simply to preach at you, you wouldn't feel it's as meaningful. This program is definitely a move in the right direction."