Imagine that you are a community health worker visiting a woman who has missed a couple of doctor's appointments. While sitting in her living room, you notice something disturbing. Just above her wrist are a series of bruises, spaced so they look like they were caused by someone roughly grabbing her arm. There's more. She's in pain, limping badly and seems very despondent. She says she has fallen lately. Maybe something is broken.
Now what? It looks a lot like domestic violence. Should the health worker bring it up? What should be the response? That was one of the scenarios experienced by the students in the Temple University Hospital community health worker program I wrote about in the Philadelphia Inquirer recently. The students were tested, one-on-one, with "standardized patients," people trained to act out scenarios or illnesses so doctors and health care providers can practice. The goal in this case was to get the woman to agree to see a doctor.
I watched some of these from the other side of a one-way mirror and I also listened to a debriefing later. Almost all the students picked up on the possibility of domestic violence, but not everyone brought it up in the conversation. I saw a 20-year-old young man attempting to counsel this woman, a prospect that horrified me. Talk about rushing in where angels fear to tread.
Another man didn't bring it up "because I thought she'd be more comfortable with a woman." Another, a woman, thought that she needed to develop a relationship with woman before she discussed something that sensitive. Others were pretty straight-forward, managing to earn the confidence of the woman enough for her to admit the situation.
Michael Curtis, a Temple professor facilitating the exercise, seemed to lean toward broaching the subject, albeit carefully. "Is domestic abuse a health issue?" he asked. "Maybe there won't be a follow-up appointment if she's dead."
Paula Stillman, the vice president of health care services at Temple University Hospital, also leaned toward talking about it. "If there's a health risk to the patient, you should approach it."
Later, I talked to one of the students, Tiffany Lovett, about her feelings. In a previous job, she had been a home visitor working with a different set of issues. She said the first thing she'd do in that scenario was to double-check her own safety. Could she get to the door for a quick escape? Was the abuser in the house? If so, she wouldn't bring up the situation.
The health of patient is important, she said, "but at the end of my shift, I want to return home to my family."
• Today: Domestic abuse: Should community health workers intervene?
• Wednesday: Who gets the savings for community health workers