Missed opportunities to catch cases of domestic abuse

Musculoskeletal injuries are the second–most-common physical manifestation of intimate partner violence. But orthopedic surgeons, who typically treat those types of injuries, refer patients to domestic violence programs at a much lower rate than providers in other specialties. 

That’s according to a recent paper by researchers at Harvard Medical School, Mass General Hospital, and Brigham and Women’s Hospital. The JB & JS Open Access article concluded that the disconnect highlights a missed opportunity for intervention by medical personnel.

“This research shows we have an opportunity to support patients in a way that can be just as important as the surgery itself,” said Ophelie Lavoie-Gagne, a clinical fellow in Orthopedic Surgery at Mass General and lead author of the study. 

In the U.S., more than one in three women and one in four men have experienced intimate partner violence (IPV) in their lifetimes, according to the National Domestic Violence Hotline. After injuries to the head and neck, musculoskeletal injuries are the most common physical manifestation of domestic violence, Lavoie-Gagne said. 

To perform their analysis Lavoie-Gagne and co-authors examined 24 years of data representing 11,227 patients referred to two unidentified, in-hospital, domestic-abuse intervention programs (DAIPs).

The researchers found that emergency departments referred 3,292, or 29.3 percent, of the patients, followed by behavioral health (18.1 percent), self-referral (14.8 percent), OB/GYN (8.4 percent), and primary care (5.2 percent). Orthopedic referrals made up the lowest relative rate across all departments at 0.3 percent. 

Screening for the violence can be as simple as asking a patient whether they feel safe at home. In certain specialties and institutions, clinicians are required to screen every patient. But in others, screening is only recommended, and clinicians aren’t always trained on what to do if a patient discloses abuse. 

The American Academy of Orthopaedic Surgeons lists common representations of domestic violence, including injuries that are disproportionate to the explanation of the cause, wounds of varying ages, and those that reflecta substantial delay before treatment was sought.

Lavoie-Gagne said surgeons who see many patients over the course of a day may miss some of the subtler signs of abuse. 

To encourage more screening, Harvard Medical School associate professor Bharti Khurana, a senior author on the paper, has been working on an artificial intelligence tool to help clinicians decide whether a patient might benefit from one.

The tool, called AIRS (Automated IPV Risk Support System), processes all of a patient’s health information and assigns a risk score. A higher score could spur a clinician to do a screening. A pilot study examining AIRS’ efficacy is underway across several departments at Harvard-affiliated hospitals. 

“IPV often leaves physical traces that show up repeatedly in the medical record long before a patient ever discloses abuse,” said Khurana. “The opportunity for AI, and for AIRS specifically, is to recognize those patterns early and objectively, using information the healthcare system already has.”

Lavoie-Gagne hopes her research helps orthopedic providers feel more comfortable screening patients more often — and understand that there are resources available.

“The intervention is not necessarily to convince someone to leave their partner; only they can decide that,” she said. “Sometimes the intervention is just to empower someone, to say that what’s happening to them at home is not okay.”

This study was funded in part by the National Institutes of Health. If you are impacted by intimate partner violence, you can call the National Domestic Violence Hotline at 1 (800) 799-7233 or text START to 88788.