Question:

A 26-year-old woman comes to the emergency department accompanied by her boyfriend for evaluation of a broken nose. With the boyfriend present, she explains that she tripped and fell in the bathroom, hitting her face on the countertop. When asked privately if she feels unsafe with her boyfriend, the patient says, "No, everything is fine. He just gets a little upset when he has too much to drink." When questioned further about how she sustained her nasal fracture, she says, "He pushed me and I fell, but I'm sure it won't happen again." After assessing the extent of the injuries, which of the following statements by the physician is the most appropriate?

"How do you know your boyfriend won't hurt you again the next time he drinks too much?"

"I can give you a list of domestic violence programs, but you have to decide if you want to get help."

"This relationship seems unsafe to me; can you help me understand why you remain in it?"

"You deserve to be safe; where could you go if you felt unsafe?"

"Your injury is concerning; do you understand why I am worried about your safety?"

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Explanation:

Assessment of intimate partner violence
Signs	Location of injuries (eg, genitals, torso, face, head, neck) Inconsistent explanation, evasive, fearful Nonadherence to follow-up, emergency department visits Partner who resists patient being seen alone Discomfort in examination, sexually transmitted infections, chronic pelvic pain
Interview strategies	Ensure privacy Nonjudgmental, empathic, open-ended questions Avoid pressuring to disclose abuse or report or leave partner Assess immediate safety; determine emergency safety plan, provide referrals for resources as needed (eg, shelters, domestic violence agency, mental health)

This patient shows several signs suggestive of intimate partner violence (IPV) (eg, head injury; inconsistent explanation of injury; reluctance to disclose, especially in partner's presence). As in this case, many people in abusive relationships do not seek assistance and may minimize or deny abuse due to shame, fear of partner retaliation, doubt that there is any alternative, or belief that the abuse is deserved.

The best initial approach is gentle, supportive, open-ended inquiry followed by a safety assessment and identification of emergency safety plans. Although the patient currently denies feeling unsafe, she should be asked if she has a plan in case violence escalates in the future. Helping the patient to develop a personalized safety plan (ie, identifying where the patient would go if feeling unsafe) is a priority.

(Choice A) Direct confrontation of this patient's denial would likely place the patient on the defensive and be perceived as unsupportive. This communication would be unlikely to overcome her reluctance to seek help for IPV.

(Choice B) Patients should be encouraged and empowered to speak to physicians about IPV. Simply providing this patient with a referral list and placing the entire burden of getting help on her is likely to leave the patient feeling abandoned and decrease the chances of her seeking assistance now and in the future.

(Choice C) The reasons why a patient stays in an abusive relationship are complex. Asking the patient why she remains in the relationship implies that she should have left; it is also likely to be perceived as judgmental and might discourage her from seeking help in the future.

(Choice E) Asking the patient if she understands why the physician is concerned is condescending and judgmental. It is a closed-ended question that would likely discourage the patient from discussing her own feelings and fears.

Educational objective:
Patients experiencing intimate partner violence should be approached in a supportive, nonjudgmental, open-ended manner. A thorough safety assessment and development of a personalized emergency safety plan are essential.