By Michele Munz, St. Louis Post-Dispatch, December 26, 2002

When Barnes-Jewish Hospital started requiring its health care providers to ask all patients if they are victims of domestic abuse, emergency room nurse Cindy Lefton said she thought it was stupid, invasive and embarrassing.

"As a triage nurse, you must figure out who is the sickest and needs to be seen first. You have someone puking their guts out in a bucket, and you have to ask them, ''Are you currently or have ever been in a relationship where someone is trying to control your life or hurt you?'' " she said. "You''ve got to be kidding me."

Her feelings changed in October 1999, a few months after the ER doctors and nurses were trained in abuse screening. A woman with hemorrhoids came into the ER with her two small children. Lefton asked the question, and the woman looked away. Not able to look Lefton in the eye, she eventually whispered a soft, "Yes." Lefton learned that the woman had been in an abusive relationship for four years. She was petrified of the man. He did not let her work or have a car. He isolated her from friends and relatives. He degraded and threatened her. She had no money and no way to take care of the children.

Lefton assured the woman of a way out. Advocates were available through the hospital who could help her develop a plan to leave her partner - and help her obtain the resources to do it.

The woman was thrilled, Lefton said, and grateful. The patient went on to get help and escape her abuser.

"It was a huge thing that happened for me personally and for this woman," Lefton said. "She must''ve thanked me 20 times, and I must''ve thanked her 30."

Lefton sees the abuse question now as part of basic medicine.

"To this day, I treat that question just like I do getting blood pressure on a patient," Lefton said. "It''s that important."

For about five years, the Barnes-Jewish Hospital policy has been to ask any patient who sets foot in the hospital about abuse. Some nurses and doctors wear buttons that say, "Is someone hurting you? You can talk to me about it."

It is the only hospital in the St. Louis area that requires domestic violence questions as part of routine screenings. Those who answer yes are directed to a program at Barnes-Jewish called Assisting Women with Advocacy, Resources and Education. AWARE is the first hospital-based domestic violence program in Missouri; the only other is in Kansas City.

It has been more than 15 years since the U.S. surgeon general declared domestic violence a public health burden - not just a law enforcement or welfare problem.

Routine hospital screening is recommended by several major national health care provider organizations, such as the American Medical Association and the American College of Obstetricians and Gynecologists.

Yet hospitals such as St. Louis University Hospital in St. Louis, St. John''s Mercy Medical Center in Creve Coeur and St. Joseph Health Center in St. Charles focus their prevention efforts only on emergency rooms, where they say most abuse victims end up.

Kris Mims, a registered nurse and clinical director of the emergency and trauma services at St. Joseph, said too much inquiry might be resented as invasive.

"Right now, our nursing staff does a good job in picking up on those details that a patient presents when she has that problem," Mims said.

But according to a study in the March 2000 edition of the Journal of the American Medical Association, 12 percent of women seeking ER care were victims of ongoing domestic violence while only 2.6 percent were screened.

Research also shows that physicians in all kinds of practice routinely see the consequences of domestic violence - defined as a pattern of coercion that includes physical abuse, psychological abuse, sexual assault, isolation, deprivation and intimidation.

Abuse victims visit physicians twice as often as others, studies show. They often have complaints unrelated to trauma, such as chronic pain and irritable bowel syndrome.

While men also may be subjected to abuse, most research focuses on women because they are considered more likely to be seriously injured.

An obligation to ask
The Family Violence Prevention Fund says health care has "a unique opportunity to intervene."

Under requirements of The Joint Commission on Accreditation of Healthcare Organizations, hospitals must train staff to recognize signs of abuse. Missouri accreditation requires it too.

Three states - California, Pennsylvania and New York - have laws requiring some form of abuse screening.

"The good news is that we as physicians are asking more than we did before," said Dr. John Nelson, spokesman for the AMA. "The bad news is that we''re not doing it all the time."

Advocates such as AWARE helped push Barnes-Jewish Hospital to go beyond basic accreditation requirements, said Tracee Champa, spokeswoman for the hospital.

As part of the pattern of abuse, many victims are kept isolated from family and friends and have little opportunity to report their plight. The only chance to talk alone to an outsider might be a trip to the doctor.

"We can break that isolation in the hospital setting," said Cathy Blair, an AWARE advocate at Barnes. "We already have females in private, confidential settings where we are asking them lots of personal questions about their lives."

Experts say that victims who do not respond or seek help may find strength in being heard and believed by a doctor, who is commonly seen as authoritative and caring. That might reinforce her capacity to seek help when she feels ready.

Said Nelson: "The very minimum is to listen, and to listen in a nonjudgmental way. The doctor''s response is the biggest factor on what the victim will do next. Dismissing it almost legitimizes what was done by the attacker."

Nelson said studies show that abuse victims are more likely to share their abuse with their physicians than anyone else, including police or clergy. Yet she said only a small percentage of physicians ask about it.

"Because we have that special relationship, we have the very obligation to ask that question ... to get information that perhaps no one else can get," said Nelson, an obstetrician in Salt Lake City.

In his office, every patient during every visit gets an opportunity to discuss abuse, he said. There is even a pen and paper in the bathroom in case that''s the only time the patient can be alone.

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