When good care isn’t emotionally driven care

Hello, folks! I am slowly getting over not matching. Slowly. I am trying to strategize for the next match. And, I’m trying to take care of myself, emotionally and physically, in the aftermath.

In the meantime, I am on my last rotation for medical school. It is a “rural selective”, which is a required elective at a rural or underserved location. I am fulfilling it at a local community health center in the women’s health department. Fun!

I am taking part in a day long orientation today. In one of the presentations, the speaker had a point on one of the slides about mandatory reporting, and included all domestic violence as falling under that category. I rose my hand and suggested that we had been trained that elder abuse and child abuse fell under that category, but other domestic violence did not. I couched that statement by saying it was controversial and I didn’t say I necessarily agreed (although I do).

One of the other attendees got very perturbed by my correction, and said I was wrong. I said I disagreed, politely. The speaker and several other attendees said they thought I was correct, and one pointed out that other vulnerable adults, such as someone with a disability, also fell under the mandatory reporting group. At the end of the speaker’s presentation, the offended woman called me out specifically, and again told me I was incorrect, but again, had nothing to back herself up other than her strong emotional response. Since this was a training on legal requirements of the job and privacy, and this population definitely would include adult victims of domestic violence, I decided to look up the law.

When I located the appropriate information, I read it out loud to the group. This nursing CEU was the first good site I found, and it had very complete information. I read this part:

Intimate Partner Abuse

Florida statute 790.24 requires healthcare providers to report gunshot or life-threatening wounds or injuries. Obviously, this does not cover the majority of injuries sustained in IPV. However, reporting suspected domestic violence without the informed consent of the victim is unethical and may cause the abuser to retaliate.

She interrupted me and said “SEE? You have to report gunshot wounds!” and I continued to read the rest of the quote. Then she angrily said “Well OF COURSE you need their informed consent!”, and I countered “Well, then that’s not mandatory reporting, is it?” She got more agitated, and started pacing the room, telling me I am saying to send these women home to get killed. I said no, and tried to explain, again, the rationale of establishing trust with the patient, many of whom are not at a place where they are ready to leave or press charges. She said she would definitely report ANY case she saw of suspected intimate partner violence, and said she didn’t want these women killed. I said that they may not press charges, and then may not trust health care practitioners again, and still get killed.

I know that IPV is a sensitive, triggering topic for many, including me. I was in a relationship with verbal and emotional abuse, and trust me, if people came on too strong about me leaving him when I wasn’t ready to, I avoided them in the future. I would not come to them when there was an incident, because I didn’t want a lecture of how it was my fault for staying. When we went over this in medical school (and I was still in my abusive relationship), one member of my small group said she was a victim of physical violence in a past relationship, and she would absolutely never press charges, she would lie to any health care practitioner or official about it, and defend him under any circumstances, when she was still in the relationship.

These victims already feel an enormous lack of control. It is not our job to control them or act for them. It is our job to be there for them on their terms. Even if it gets us emotional.


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11 responses to “When good care isn’t emotionally driven care

  1. Your post highlights how we, as medical professionals, can sometimes do harm by trying to fix the situation. We sometimes have a very self-righteous belief that we know what’s best for a patient, and we want to just do something to make things better, whether it’s what the patient wants or not. As you illustrate, it’s better sometimes to develop an ongoing relationship with a patient in the hope that you can support them through the process of gradual change than it is to force them into making a sudden change for which they aren’t ready.

  2. I absolutely agree with you. The goal should be to minimize the harm to the patient, not to do the “right thing” at the moment. The laws designed to protect against domestic violence do a poor job, so reporting the abuser could easily result in more harm being done to the victim.

    • MomTFH

      It’s hard to keep the big picture in mind for some clinicians if we don’t work hard to step back from our gut emotional response.

  3. Jim

    Although I live in the UK , the first and third sentences , of that statute , seem to cancel each other out .

    • MomTFH

      That is not the wording of the statute. It is the wording from the continuing education module discussing the statute. Yes, it does suggest that any notification may be unethical, even if it’s life threatening.

  4. Tenya

    Unfortunately, what I think the other attendee and many people are under the impression of is that mandatory reporting always results in an arrest with the perp never bothering the victim again, either because of being in jail or because the power of the restraining order keeps them away. Obviously, if that were the case, we’d say mandatory reporting for IPV is great and we’d all use it. But it isn’t. Mandatory reporting endangers victims more because our legal system cannot protect victims like it can children or the elderly, who can be packed off to institutions and not let them go back to the person who abuses them (at least, in the case of children, until they’re 18). It doesn’t take into account that assault isn’t a life sentence even if there is a conviction, and that restraining orders are not magic, and further that abusers work really hard at enmeshing themselves into their victims lives so that “just leaving” is difficult if not impossible.
    It is really hard as a health care worker to accept IPV as a chronic issue. We want to help! We want to do something! It can be really hard to accept that doing nothing (other than being supportive) is the best course of action.

    • MomTFH

      Great reply, thanks!

      The few people I have discussed this with in people, (all men, maybe not by coincidence), assume that this other attendee was reacting in such a way because she has a personal issue with IPV. I think your interpretation is much more likely. I think it was apparent that this woman does not have a lot of experience with IPV in her life, and thinks it is a black and white issue – name it, change it, wash your hands of it.

  5. Jay

    I’d say that emotionally-driven care is generally a good idea as long as the emotions at the center are the patient’s, not the clinicians. We’re not in this to make ourselves feel better.

    That’s one of the many, many reasons why it’s important to reflect on, understand and care for our own emotional states – so that we don’t make decisions about patients based on our own needs and assumptions.

    Tenya is completely right about the difficulty of accepting IPV as a chronic issue – although I think clinicians have difficulty facilitating and supporting behavioral change in many settings. We become equally frustrated with the patient who doesn’t magically stop eating carbs as soon as we tell them they have Type 2 diabetes…

    • MomTFH

      Thanks for making two great points. I definitely agree the answer isn’t emotionless care. The patient’s emotions should be central to guiding empathetic care, and a clinician really needs to work hard to keep her emotions from affecting care negatively.

      Also, yes, many clinicians place a little too much stake in behavior changes in the first place, and underestimate how difficult behavior changes can be.

  6. Pingback: My post on reporting abuse on KevinMD | Mom’s Tinfoil Hat

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