“You need to come to the ED ASAP.”

A new patient was admitted at 2 a.m. and requested for a crisis counselor. Unlike with cases of sexual assault, survivors of domestic violence had to specifically request for the presence of an advocate when I was volunteering in NYC back in 2009. This woman, I’ll call her Sadie, had already taken the first courageous step to seek help.

I briskly walked past distressed family members looking anxiously around for a glimpse of a messenger bearing good news. After knocking on the door asking for permission to enter, I walked in to find Sadie struggling to rest her left leg covered with blood. Completely abandoning the usual protocol for first explaining my role and how I could best support her, I blurted out, “What happened?”

Sadie and her friend, who was in the room as well, recounted how they were at a club when they were confronted by a violent woman who was later revealed to be the new girlfriend of Sadie’s ex-boyfriend. She began to punch Sadie and Sadie said she was able to fight her off. However, soon after, Sadie was attacked by her ex-boyfriend who broke a beer bottle over her leg.

I winced as I looked back at her leg.

I told Sadie that I was glad she was now safe and getting care. I would be there to help make sure her medical and other needs were met and could help if she decided to go ahead and press charges. Only once during my three years as a crisis counselor did a survivor of domestic violence or sexual assault decide to go ahead and press charges. The process itself can be re-traumatizing in many ways.

After several hours, the attending physician came in to check on Sadie. She was very efficient when it came to cleaning the wound and taking out the small pieces of glass. As per protocol, I then presented her with the domestic violence medical forms. She expressed that she was pressed for time, so I offered to pre-fill as much as I could but that she needed to provide the medical documentation of the incident. The physician then looked directly at me and exclaimed, “This is not a domestic violence case. Domestic violence happens in the home. She was in a club.”

I tried to quickly mask the look of pure horror on my face. I began to rebuke but Sadie began saying in the background, “It’s alright. It’s not that big of a deal. I’ll be fine.” The physician quickly ducked out.

So if one is going to get super technical, domestic violence would only happen in a domestic setting. Perhaps this is why the term intimate partner violence may work better in some cases. But it was nevertheless dumbfounding to me that a physician, who first goes through years of rigorous education and training and is an esteemed professional that I was aspiring to become, would succumb to such a narrow and literal interpretation of domestic violence.

And, yet, when evidence suggests that domestic violence survivors are more likely to interface with the health care system and the abuse is associated with poor health outcomes, physicians need to be doing a better job at creating a space in which survivors feel comfortable with reaching out for help.

After all, for better or worse, the white coat gives the physician a significant amount of authority. Physicians can help validate patients’ concerns and through a non-judgmental, respectful approach, can encourage survivors to speak up about their abuse.

Identifying abuse in the clinical setting is key. In January 2013, the U.S. Preventative Services Task Force announced that it now “recommends clinicians screen women of childbearing age for intimate partner violence (IPV), such as domestic violence, and provide or refer women who screen positive to intervention services.” This is a great step towards addressing the epidemic of domestic violence.

But it doesn’t completely address the frustration that many physicians experience when confronted with the vast complexities of domestic violence. In many ways, they too may be grappling with the following question:

Why don’t people in abusive relationships just leave?

This is a question that is all too often asked. There are numerous barriers that prevent survivors of domestic violence from leaving abusive situations such as racism in the criminal justice system, immigration status, and fear for one’s safety, just to name a few. Financial barriers also play a significant role.

Recent estimates show that approximately 94 percent of domestic violence survivors have experienced economic abuse. Economic abuse can entail preventing the survivor from keeping employment, engaging in credit-related transactions and subsequently accruing debt in the survivor’s name without his or her consent, and/or prohibiting the survivor from accessing current funds. Even if a survivor is able to escape, crippled financial literacy can pressure the survivor to return to the abusive situation.

Furthermore, a lack of affordable housing can prevent survivors of domestic violence from escaping abuse or otherwise generate dire circumstances for those who have managed to leave. One report by the ACLU found that half of all cities in the United States point to domestic violence as a primary cause of homelessness. In response, states like New York have announced plans to expand emergency housing for domestic violence survivors.

Yet, increasing access to safe and affordable housing is just one component of economic empowerment for survivors of domestic violence. In order to truly support economic empowerment, organizations providing services to survivors of domestic violence must assist them in areas such as securing further education or training, subsidizing childcare, and even something as speciously basic as attaining a driver’s license. Education, child-care, and access to transportation are each vital to a person’s capacity for both securing and maintaining employment. Indeed, such factors have previously been shown to comprise the most common barriers to low-income women’s employment.

Indeed, domestic violence is both a complicated and an urgent issue that needs to be addressed by the health care profession. Some suggest mandating each and every physician to undergo training on how to conduct effective screening for domestic violence. While such training may help ensure that fewer physicians are ignorant or incompetent regarding domestic violence, such as the attending I, unfortunately, encountered in the ED, it won’t adequately address the complexities of domestic violence on its own.

Physicians should certainly be entrusted with taking appropriate measures to identify survivors of domestic violence and document medical evidence accordingly. However, the burden of addressing all of the psychosocial factors contributing to the abuse cannot realistically fall solely on their shoulders. Greater investment in resources and professionals who can support a more team-based approach to addressing the epidemic of domestic violence in this country is sorely needed.

Tehreem Rehman is a medical student who blogs at her self-titled site, Tehreem Rehman.  She can be reached on Twitter @tehreem_rehman.

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