Dr. Brigid McCaw was diligently working her way through medical school while her sister was busy concealing a secret. Despite the summer heat in her Denver home, McCaw’s sister bundled up in high-necked layers. The bruises along her abdomen became difficult to conceal during pregnancy, but her own physician never questioned them. Immersed in her studies at the University of California, San Francisco almost 1,000 miles away, McCaw never even saw the black and blue marks.
“I was learning how to save lives and I didn’t really understand that she was also trying to figure out how to save her life and was in a very abusive relationship,” McCaw said recently from her bustling office in Kaiser Permanente’s downtown Oakland facility. “Our family didn’t really understand what was going on. She was trying to handle things herself and she was so embarrassed. She was smart, talented and caught in a situation she didn’t know how to get help for—and there wasn’t any.”
The lack of available resources and information left McCaw’s sister in a life-threatening situation. “One night, he choked her and she went to the local fire department,” McCaw said. “They said, ‘Honey, we’re sorry, but we don’t have any way to help.’”
McCaw, now 57, sat down recently to reflect on how domestic violence awareness and prevention has changed since she first learned of her sister’s suffering. US Congress passed a law in 1989 officially designating October as National Domestic Violence Awareness Month. Health professionals around the country have been observing the month with conferences and events, while some, like McCaw, have also commemorated the past struggles of friends and family.
McCaw’s sister was eventually able to leave her violent partner, but felt compelled to relocate across state lines with her then two-year-old daughter to escape the abuse. Watching her sister endure the life-changing ordeal profoundly affected McCaw’s perspective on health care. “It led me to make a commitment that I would do better than what she had experienced,” she said.
Ten years after discovering her sister’s abuse, McCaw began working in the emergency department of Kaiser’s Richmond Medical Center. Though she’d vowed to identify and address signs of abuse she recognized in patients, offering help was harder than she realized.
“Everybody knew that family violence was a big issue, and that the healthcare setting had a really important role and yet no one was able to show that they were doing anything meaningful about it,” McCaw said in a conversation this month. “I didn’t know what to ask, how to respond or who to ask for help and what was out in the community. That was the impetus for me to say, ‘What would I need, as a doctor, to make this be something I could deal with the same way I deal with heart disease or broken legs or lacerations?’”
McCaw felt that what she and other physicians needed was a comprehensive model of care to tackle domestic violence like any other life-threatening illness or injury. So in 1998, she helped launch the The Family Violence Prevention Program (FVPP) in Richmond. The program encourages physicians to ask questions about patients’ home lives, regardless of whether there are signs of abuse. Through lectures and online tools, FVPP teaches employees how to ask those questions, and what to do if a patient admits to abuse.
McCaw said the program helped triple the number of patients identified as domestic abuse victims at the Richmond facility. Kaiser has since expanded the FVPP to all its Northern California facilities, where multiple posters and brochures show patients in violent relationships how to ask for help, and where to find information and resources. Centers throughout the country are now in various stages of implementing the model, and in August the U.S. Department of Health and Human Services (HHS) adopted a list of new guidelines ensuring that domestic violence screening be included among preventive health services women should receive at no additional cost.
The guidelines are a result of recommendations made by the Institute of Medicine (IOM), an independent nonprofit that advises decision-makers and the public. An HHS press release says the new guidelines require new health insurance plans to cover women’s preventive services “without charging a co-payment, co-insurance or deductible.”
“You don’t get a lot bigger incentive than this, for HHS to say this needs to happen and it will be paid for,” McCaw said. “You can recommend all the things you want and the IOM is a very prestigious organization, but in the end it’s a recommendation. When you link a recommendation with HHS saying, ‘and you will provide this as a healthcare plan,’ then you’ve got the two in concert.”
McCaw said the new guidelines are an important incentive for health care providers to look for signs of domestic trouble before they turn to abuse.
“It’s no longer waiting until someone looks distressed or has an injury—we’re actually reaching out to them before,” McCaw said. “The data is very clear: the longer abuse lasts, the more deleterious the health effects are, and the more severe it is, the more deleterious the effects are.”
One problem with traditional domestic violence treatment, McCaw said, is that it rarely addresses the issue until victims are severely injured, and it overlooks non-physical elements of abuse. “Things like emotional abuse also are as impactful as physical abuse, but it’s not going to show up in the emergency department,” McCaw said. “So if we’re identifying people in primary care, hopefully we’re able to intervene sooner, and to reduce the number of serious cases coming from long duration or more severe abuse.”
Kaiser’s statistics and other nationwide data suggest that domestic violence is still both common and potentially very dangerous. According to the Centers for Disease Control, one in four women has experienced domestic violence in her lifetime. In 2007, Intimate Partner Violence (IPV), defined by Futures Without Violence (formerly known as The Family Violence Prevention Fund) as abuse “perpetrated by someone who is, was, or wishes to be involved in an intimate or dating relationship with an adult or adolescent,” accounted for 2,340 deaths, according to the CDC. Nearly two-thirds of those victims were female.
McCaw believes that HHS’s decision to encourage free preventive care will prompt doctors to offer more of these services, and patients to seek them out. “If someone is coming in for a routine checkup, we ask our doctors to find out more about them,” McCaw said. “‘Where do you work?.’ ‘Who lives with you, and how is it that going?’ We want them to become familiar with patients in situations where it opens the door for asking questions about sensitive topics.”
Patients with chronic problems seemingly unrelated to domestic violence may also be asked questions about their current living situations. “If a patient comes in with certain conditions like recurrent headaches, abdominal pain, or sleep problems, those are the kinds of conditions we’d like doctors to ask additional questions like, ‘How are things at home?,’” McCaw said. ”‘Have you ever felt physically or emotionally hurt or threatened by your partner?,’ ‘Are you being hit, hurt, choked or slapped by your partner?,’ ‘Do you ever feel frightened of your partner?’”
“A woman I saw in the late 1990s was in a very abusive relationship, and no one had talked to her about it,” McCaw recalled. The women, who had been seeing McCaw for chronic headaches, finally talked about her abusive partner after McCaw asked specifically about her home life. McCaw referred the woman to a domestic violence support group. “I didn’t see her until five years later, when I was working in urgent care and she had a back strain,” McCaw said. “I asked how things were going. We had a quiet moment, and she said, ‘You know, my ex is in prison. I have a job that I love, my daughter is 14 years old, and I’m taking parenting classes so I can do a better job with her than I experienced.’ She said ‘Kaiser made all the difference for me.’ You live for things like that.”
One important element of the Kaiser’s integrated approach has been a multi-panel exhibit known as the silentWitness display. Dedicated to the memories of three Kaiser employees murdered as a result of domestic violence, the silentWitness displays portray personal stories of physicians, staff and employees touched by the issue.
“We decided it would be effective to get the voices of all our employees of all different ethnicities, of all different job descriptions, all different ages, and ask them to share their stories,” McCaw said. Kaiser facilities in Sacramento, Antioch, San Rafael and Walnut Creek are currently hosting displays throughout the month of October, and the stories are universally available on the FVPP website.
Though her sister successfully escaped abuse and seemingly rebuilt her life, McCaw expressed regret that more resources were not in place at the time to aid in the process.
“I wish that she could have stayed near us and had counseling and been able to re-find her self-worth more rapidly and not to have done it all by herself,” McCaw said. “She moved to a new place, found friends, got a job, started teaching school and made sure she was in a community that was supportive and safe. Ultimately, over time, she got her master’s degree and her daughter has her master’s degree and they’ve done well. But it’s also true that she’s never had another intimate relationship.”
McCaw hopes Kaiser’s program, as well as domestic violence prevention efforts nationwide, will help women like her sister end the abuse cycle earlier and rebuild their lives without uprooting them. She also hopes to reach a wider variety of people. “That includes older women, men, our members of color, our members who are not English-speaking,” she said. “I think we try, but we could do a lot better job. I’d like to see us go younger so we could do a better job with teens and also children who are in homes with domestic violence.”
For McCaw, doing a better job also means talking to patients about what a healthy relationship means. “I usually say a healthy relationship is honest, caring and respectful,” she said. “If I’m seeing a person coming in for sore throat or a cold and I ask if they’re in a relationship, I may ask them, ‘Do you ever feel emotionally or physically threatened?’ Most of the time the answer is ‘no.’ But I always ask — because healthy relationships are important to health.”