Tricky Scenario Secondary Prompt

[thehighlander]

Hi everyone,

Could use some help in brainstorming possible responses to a secondary scenario prompt from Virginia Commonwealth. The prompt in mind was: "Imagine that you are a medical student taking an admission history of a woman for a minor surgical procedure. She is accompanied by her husband who is very friendly and overly eager in answering your questions. The husband leaves to pay the parking meter and you proceed with your physical examination of the wife. You notice some bruises on her upper arm. When you ask about the bruises, she states that she recently fell in the kitchen and asks you not to bring it up when her husband returns. You suspect domestic violence. How would you handle this situation? (You may use any resources for your answer) "

Are there any privacy laws I need to consider as I form my response? Any ideas on the most appropriate way to handle this situation? Thanks!

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[thehighlander]

Any ideas?

 

[nRomaleos]

Any ideas?

http://www.dhp.virginia.gov/dhp_laws/Legal Requirements to Report Abuse.doc

 

[Goro]

How about growing a spine, and some ethics, and answer this on your own after doing some research?

Hi everyone,

Could use some help in brainstorming possible responses to a secondary scenario prompt from Virginia Commonwealth. The prompt in mind was: "Imagine that you are a medical student taking an admission history of a woman for a minor surgical procedure. She is accompanied by her husband who is very friendly and overly eager in answering your questions. The husband leaves to pay the parking meter and you proceed with your physical examination of the wife. You notice some bruises on her upper arm. When you ask about the bruises, she states that she recently fell in the kitchen and asks you not to bring it up when her husband returns. You suspect domestic violence. How would you handle this situation? (You may use any resources for your answer) "

Are there any privacy laws I need to consider as I form my response? Any ideas on the most appropriate way to handle this situation? Thanks!

 

[thehighlander]

How about growing a spine, and some ethics, and answer this on your own after doing some research?

That's what I've been doing all morning. No need to get nasty, just trying to get the ideas flowing.

 

[thehighlander]

http://www.dhp.virginia.gov/dhp_laws/Legal Requirements to Report Abuse.doc

Thanks nRomaleos!

 

[vellez]

You're not expected to know the laws of Virginia nor necessarily even the medical obligations. Based on your life experiences, what do you feel to be the most "right" response? Obviously doing a bit of quick research shows that you are thorough, but elaborating on the specific statutes is quite boring.

 

[CaliforniaDreamer]

I am a believer in the autonomy of competent adults. Any actions I took would be limited to questions/advice unless there was some belief of great harm.

 

[aalamruad]

How about growing a spine, and some ethics, and answer this on your own after doing some research?

Note: "You may use any resources for your answer." SDN is a resource. Nothing cowardly or unethical about asking for advice on advice forums.

So unnecessarily rude. Check out SDN's TOS #2:
"Be courteous and contribute positively. If you’re not contributing to the forums in a positive manner, you may receive a warning or have your account temporarily or permanently closed."
Or are you above the law since you're a big name on these forums?

 

[Goro]

I'm from NY, where use the term "F you" as a greeting. Don't ever there if you're that thin-skinned. OP deserved the smack upside the head for expecting SDN to do his/her work for them.

 

[deleted393595]

Hi everyone,

Could use some help in brainstorming possible responses to a secondary scenario prompt from Virginia Commonwealth. The prompt in mind was: "Imagine that you are a medical student taking an admission history of a woman for a minor surgical procedure. She is accompanied by her husband who is very friendly and overly eager in answering your questions. The husband leaves to pay the parking meter and you proceed with your physical examination of the wife. You notice some bruises on her upper arm. When you ask about the bruises, she states that she recently fell in the kitchen and asks you not to bring it up when her husband returns. You suspect domestic violence. How would you handle this situation? (You may use any resources for your answer) "

Are there any privacy laws I need to consider as I form my response? Any ideas on the most appropriate way to handle this situation? Thanks!

Tell the wife that you need to see her in private. Mention the same to her husband when he comes back. And then talk to her about it. For all you know, they could be into some really... uhm........ "weird" stuff and are ashamed of bringing it up.

 

[Affiche]

For all you know, they could be into some really... uhm........ "weird" stuff and are ashamed of bringing it up.

Eeeek! I will caution you against remaining overly optimistic in such situations. Many victims of domestic abuse want the abuse to end, not the relationship, and they may lie to protect their abuser until they're ready to leave. The victim may not be ready to leave the abusive situation and nothing you say can force them into that position. The truth is that a large percentage of victims of IPV go through the ED unnoticed as such, and remaining overly cautious about suspecting abuse can be harmful.

 

[CaliforniaDreamer]

Eeeek! I will caution you against remaining overly optimistic in such situations. Many victims of domestic abuse want the abuse to end, not the relationship, and they may lie to protect their abuser until they're ready to leave. The victim may not be ready to leave the abusive situation and nothing you say can force them into that position. The truth is that a large percentage of victims of IPV go through the ED unnoticed as such, and remaining overly cautious about suspecting abuse can be harmful.

What are you going to do if they don't want to talk about it/do anything about it?

 

[Affiche]

What are you going to do if they don't want to talk about it/do anything about it?

Document the hell out of what's causing me to suspect abuse and leave a paper trail of evidence in case the victim ever decides to pursue legal action.

 

[CaliforniaDreamer]

Document the hell out of what's causing me to suspect abuse and leave a paper trail of evidence in case the victim ever decides to pursue legal action.

Seems like you would document injuries and bruising regardless of the cause though? What would you do differently in this instance.

 

[Affiche]

I'll leave that unanswered so you can research your own plan of action

 

[CaliforniaDreamer]

I'll leave that unanswered so you can research your own plan of action

I'm not the OP though

I wish I had secondary questions like this...

 

[nRomaleos]

Seems like you would document injuries and bruising regardless of the cause though? What would you do differently in this instance.

again, as the link shows, you are actually legally liable to report suspected abuse as a healthcare professional.

 

[CaliforniaDreamer]

again, as the link shows, you are actually legally liable to report suspected abuse as a healthcare professional.

I have only heard about mandatory reporting for child/elderly abuse.

 

[Affiche]

I have only heard about mandatory reporting for child/elderly abuse.

+disabled adults.

 

[nRomaleos]

I have only heard about mandatory reporting for child/elderly abuse.

yes, disabilities as well.

 

[CaliforniaDreamer]

Right, that's why I said "competent adult" in my first post. I wonder if this question is testing whether or not you consider this woman to be competent. I would say yes she absolutely is, although the way the question is constructed I feel like it would push some people to jump into the option of taking action on her behalf.

 

[LizzyM]

I would keep in mind that your role in this scenario is as a medical student. Do you imagine that taking a history and performing a physical is something you do independently and then make an assessment and formulate a plan on you own and then carry out that plan without anyone's review or approval or as you imagine yourself as a medical student are you not acting independently? If you would not be acting independently, who would be supervising you? How might you interact with your supervisor in this instance?

 

[Goro]

And the concrete overshoes. Take him to go meet Jimmy Hoffa.

Youse ain't just from NY, youse from Brooklyn. You want I should get the boys and the shovels?

 

[deleted393595]

I'm from NY, where use the term "F you" as a greeting.

As someone who grew up accustomed to Southern hospitality:

Eeeek! I will caution you against remaining overly optimistic in such situations. Many victims of domestic abuse want the abuse to end, not the relationship, and they may lie to protect their abuser until they're ready to leave. The victim may not be ready to leave the abusive situation and nothing you say can force them into that position. The truth is that a large percentage of victims of IPV go through the ED unnoticed as such, and remaining overly cautious about suspecting abuse can be harmful.

That could absolutely be the case, and that's why I mentioned in my post that I would talk to the patient in private about it (which I should've made clearer - my mistake).

But unless my patient explicitly states that she's a victim of IPV, I'm limited in what I can do as a physician short of documenting everything, as you excellently suggested. I must also consider other alternatives, and without clear proof, I would be hesitant to unleash the legal machinery of the government on the husband, who may be innocent.

 

[doc05]

Imagine you are the medical student who is forced to take an exam on your own.

Imagine you are a physician and you have to make a decision on your own.

 

[Affiche]

@ElCapone at least in my opinion, it doesn't matter much what the wife says the bruising is from. If I suspect abuse then I would document that I suspect it. When I say I'd leave a paper trail, I mean that I would document if the bruising is consistent with injuries from abuse and that I suspected IPV. Simply taking a patient's word that she fell or is into kinky sex may result in documenting the injury as general bruising, which may not help the victim if she ever decides to pursue legal action.

 

[Syns]

Rachiie seems mature about the situation but also the bruising isn't sufficiently described. The best response remains to be meticulous in documentation however, I would be wary of overtly stating inferences. They can open the door to scrutiny in the court room after a grievance has been filed. You might end up hurting her case.

"During the routine visit, four circular bruises were discovered on the patient's upper left extremity. Three on the posterior and one of the anterior. The posterior abrasions were roughly 1-1.5 cm in diameter while the anterior was larger (2.0 cms in diameter)." Include the patient's word-for-word response when questioned about the injury.

Throwing in a "consistent with the husband's hand size" could allow the defendant wiggle room. Subsequently leading to evidence being demonized as bias.

It's complicated...

 

[deleted393595]

@ElCapone at least in my opinion, it doesn't matter much what the wife says the bruising is from. If I suspect abuse then I would document that I suspect it. When I say I'd leave a paper trail, I mean that I would document if the bruising is consistent with injuries from abuse and that I suspected IPV. Simply taking a patient's word that she fell or is into kinky sex may result in documenting the injury as general bruising, which may not help the victim if she ever decides to pursue legal action.

But if you document that you suspected abuse, are you also mandated to report it?

 

[nRomaleos]

But if you document that you suspected abuse, are you also mandated to report it?

It seems that you might not be, unless there is reason to assume that this lady is handicapped or incapacitated in any way.
I am not sure if fear of abuse can be a psychological handicap?

This one is getting crazy now...

 

[Affiche]

But if you document that you suspected abuse, are you also mandated to report it?

I think it depends on the state that you're in. As a medical student, you should be reporting your findings to your higher up regardless of suspecting abuse or not. As the higher up, I think as long as the adult is competent then it's up to you to file a formal report (depending on state laws).

I shadowed a very close family friend who is an ER attending for about 200 hours (~20 shifts). We spoke a lot about ER policies, including abuse. This is n=1, but based on the physicians I discussed this with in the ER they all seemed vehemently against policies that mandated reporting. There are lots of issues with reporting against a competent adult's wishes, but the most pressing ones involve
1. losing your patient's trust
2. scaring them into not seeking medical attention in the future
3. causing their abuser to retaliate.

 

[CaliforniaDreamer]

It seems that you might not be, unless there is reason to assume that this lady is handicapped or incapacitated in any way.
I am not sure if fear of abuse can be a psychological handicap?

This one is getting crazy now...

I think this is would actually be a really bad view to take, I think it would demonstrate paternalism, a lack of belief in the autonomy of competent adults or their right to make their own decisions.