Putting Together the Pieces

Radiologists sometimes hold the key to diagnosing inter-partner violence, but are they watching for the signs?

puttingpieces 

Do a search in PubMed for “domestic violence,” and you will discover over 40,000 results. Add “radiology,” and the numbers drop to 836. Now eliminate the articles dealing with child and elder abuse from that search —meaning you are searching only for information on inter-partner violence — and the numbers go down to just 19.

Inter-partner violence, particularly violence against women, is at epidemic proportions, affecting about one third of women worldwide. And it isn't just a problem in underdeveloped countries. One in four women and one in seven men in the United States have experienced severe physical abuse by an intimate partner. There is a surprising disparity between the rate at which domestic violence occurs and the amount of medical imaging literature related to domestic violence. The dearth of literature on the topic could represent a low awareness of inter-partner violence among some radiologists. It is important that radiologists consider domestic violence as a possible diagnosis as they work through their cases. Imaging findings can play a crucial part in uncovering cases of domestic abuse, and radiologists have the interpretation skills to find the more subtle symptoms.

Digging Deep

There are a variety of reasons inter-partner violence may not be at the forefront of a radiologist’s mind. One reason may simply be the number of cases that come across a radiologist’s desk. Timothy V. Myers, MD, chief medical officer for Direct Radiology, LLC, who frequently reads emergency department cases, notes that because radiologists have such large caseloads, domestic violence might slip their notice because the signs can be very subtle and take some digging. Such clues as older fractures, which would indicate that these injuries had occurred before, may take time to uncover. “Finding some of these signs is a lot like detective work. If you’re in a hurry, the subtle things are the first ones you start missing,” Myers says. Another reason inter-partner violence is often overlooked relates to the taboo surrounding the topic. Domestic abuse remains a largely un discussed, and perhaps misunderstood, subject. “A lot of people don’t realize that when adults are in these situations, it’s not any better than when the victims are children,” says Sonya Bhole, MD, a radiologist at Northwestern University who has published on the topic. Some individuals might believe that because the victims are adults, they should be able to seek their own care and would readily indicate the cause of their injuries in their medical histories. “When children are the victims, we raise the alarm quickly because the child cannot leave or easily report the situation. But adult victims cannot necessarily leave either. And even if they leave the situation, the risk of violence doesn't end,” says Bhole. Radiologists’ awareness of the warning signs may also be affected by the location of your practice. If you are in an urban trauma center and frequently see assaults, you may be more inclined to suspect domestic violence, says Myers. But in suburban or rural areas, radiologists may not see the more obvious cases as frequently, so the subtle cases may escape notice. And, says Richard B. Gunderman, MD, FACR, chancellor’s professor at Indiana University and author of many publications on ethics in medicine, “Many of us may be failing to consider domestic violence because we’re operating under the assumption that it’s an unusual phenomenon.”

 

Taking Action

So how do you make sure you identify inter-partner violence when you come across it? Always operate under a level of suspicion, says Myers. Approach cases assuming you will find something you don’t expect. He notes that radiologists reading pediatric cases review every patient for signs of abuse, and it should be the same with adults. Gunderman adds that radiologists should look for certain patterns of injury. Although things like orbital blowout fractures and nasal bone fractures can be accidental, they are frequently a result of direct trauma, such as punching. Gunderman also says one of the most important things is to pay attention to the patient history. Note the injuries and make sure they match up with the story the patient has given. If something seems amiss, quickly call your referring physician. “You can’t just put it in the report and hedge it,” says Myers. “There is a likelihood that the ER doctor will misunderstand you, and the case will fall under the radar.” And don’t assume that your referring clinician has already suspected abuse. Both Bhole and Myers noted several times they called and the clinician had no suspicion at all.
When you’re speaking with your clinician, first try to get a more complete patient history. Sometimes, the patient may have a history of abuse that wasn't put into the medical record, notes Bhole. Other times, suspicious indicators have easy explanations, such as sports injuries. Radiologists who want to be more aware should also look to the principles of Imaging 3.0™. By being more patient centered in their practice, radiologists may notice things that have been left out of medical histories, allowing them to pinpoint more discrepancies that arise.

Facing the facts

Domestic violence might be more common than you think. Take a look at some recent statistics:

 

Starting a Conversation

Technologists can also play a key role in helping identify domestic violence, says Gunderman. “They’re the ones who see and interact with the patient. They can tell you if the patient was behaving in an odd fashion, or if there were physical signs such as bruising,” he notes. The best way to catch domestic violence when it comes across your caseload is to be aware and promote awareness among your colleagues, say both Bhole and Myers. Building awareness can be as simple as sharing your cases with your colleagues, adds Myers. Seeing examples in their own patient population may spark physicians’ interest and keep the issue on their minds as they go through their cases. Another way to spread the word is to add to the current literature. “We need more case studies,” says Bhole. “If we as radiologists document inter-partner violence more, we can start conversations about domestic abuse in other places, such as residency curricula and at conferences, educating more radiologists and making them more aware.” And as radiologists become more aware of domestic violence, they will be better prepared to work with their referring physicians to support their patients. “It’s important that we find and diagnose these cases when we can,” says Myers. “Victims of domestic abuse can come in one day with a broken arm and be dead several weeks later. Abuse escalates.”

 

Looking at the law

Disclosing patient information such as the possibility of abuse may raise concerns about legal implications. Here is a quick run-down of HIPAA’s stance on domestic abuse. As always, however, check with legal counsel should you have any concerns.

  • Under HIPAA, a radiologist can disclose to a referring physician the patient health information (PHI) of a patient who the radiologist suspects is the victim of domestic abuse.
  •  HIPAA also allows radiologists to disclose PHI to government authorities who are authorized to receive reports of domestic violence. This comes with some stipulations, however.
  • A radiologist may report if laws require such disclosure, if the patient agrees that the radiologist can disclose the information, or if the radiologist believes that disclosure
  • must occur to prevent serious harm to the patient or other potential victims.
  • Since most states have laws requiring physicians to disclose suspected domestic abuse to police or other specified authorities, HIPAA should not be an impediment for physiciansin such situations. In fact, a physician’s failure to make such a report may actually be acrime. See Cal. Penal code §§ 11160-11163.2 for an example.

By Meghan Edwards

 

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