Broaching topics patients may not want to talk about

Scenario: Internist Dr. Warren, who has had both Mr. and Mrs. Doane as patients for three years, suspects that Mrs. Doane is being physically abused and has tried to get her to talk about her home life. He has offered her pamphlets with hotline numbers and information about health and legal resources for domestic violence. Mrs. Doane has never admitted she is being abused and refuses to answer Dr. Warren's direct questions. She leaves the pamphlets in the exam room.

Reply: Increasingly, health care professionals are expected to regularly and competently screen patients for violence in intimate relationships. Studies have found that women in abusive relationships use more health care services and will often access the health care system multiple times before the abuse is detected. Consequently, health care professionals are in a unique position to regularly encounter women who are survivors of violence.

The case of Dr. Warren and the Doane family highlights the fact that many intimate partner violence survivors do not readily disclose abuse, even when faced with a direct inquiry. Physicians with expertise in treating domestic violence admit difficulty in identifying the presence of abuse in all cases.

Research has found that women might choose not to disclose abuse because of shame, guilt or fear of perpetrator retaliation. Both survivors and their physicians have identified patient distrust of the health care professional as another barrier to abuse disclosure.

One recent study of trust in the patient-physician relationship identified certain physician behaviors that can facilitate trust and, thus, make patients more comfortable and more likely to talk about abuse. Many of these behaviors are the foundations of a patient-centered approach in which the doctor and patient share power and responsibility through a therapeutic alliance.

Survivors describe trusted physicians as those who engage in open communication where medical decision-making is a joint effort. After feeling like they're under the power and control of their perpetrators, this approach allows survivors to feel a sense of control in their own lives. Physicians who make an explicit statement about the confidentiality of the patient-physician relationship may gain patient trust, especially when the use of information has potential consequences for the patient, such as retribution from the abuser or involvement of child protective services.

Survivors of domestic violence are more likely to trust physicians who are familiar with them through repeated encounters and who show their concern through nonjudgmental and empowering statements or gestures.

With patients who do not disclose abuse, physicians should persist with repeated but sensitive questions to show that they care, while respecting the patient's decision not to disclose. A physician may consider sharing personal information with the patient to eliminate the inherent imbalance of knowledge and power in the patient-physician relationship and facilitate the patient's trust.

In this case, Dr. Warren has the benefit of an established relationship and repeated encounters with Mrs. Doane, which encourages a trusting relationship. The fact that Mr. Doane is also under Dr. Warren's care, however, threatens that relationship and may heighten Mrs. Doane's fear of retribution from her perpetrator if she talks to Dr. Warren about the abuse. Emphasizing the confidential nature of the patient-physician relationship is imperative in this case. Of course, physicians must be careful to also make the limitations of that confidentiality explicit, as in the case of mandatory reporting of active child abuse.

Even though Mrs. Doane has chosen not to disclose her abuse at this time and may continue not to, Dr. Warren has made a powerful intervention. Studies have shown that survivors find it useful and empowering when health care professionals offer them education and refer them to community resources.

In the absence of on-site resources, an often-cited barrier to direct physician inquiry, physicians can easily provide statewide hotline numbers and program information.

Furthermore, the ongoing nature of the patient-physician relationship allows for repeated direct, nonjudgmental questioning. By being respectful of Mrs. Doane's decision not to disclose, Dr. Warren leaves the door open for future encounters where trust can be further established. A statement such as, "You don't deserve this," may go a long way for a woman who has never been told such abusive behavior is not acceptable.

Medical professionals must go beyond the traditional biomedical approach when caring for survivors of intimate partner violence and address patient-identified needs first.

Physicians should foster both a trusting relationship and disclosure of abuse through persistent and repeated questioning.

Identifying violence through disclosure is therapeutic in itself; it validates the presence of an intensely private matter, which is a requisite step in the healing process.

Tracy Battaglia, MD, MPH, assistant professor of medicine, Boston University School of Medicine; research director, National Center of Excellence in Women's Health at Boston University Medical Center

Scenario: What is the best way to open a discussion about obesity?

Ms. Lang is a 45-year-old, single woman who weighs 235 pounds. When she sees her physician, Dr. Elliot, she doesn't talk about her personal life or linger to discuss anything other than the treatment for her presenting illness. She doesn't get annual physicals. Dr. Elliot wants to talk to her about the danger of being overweight and the importance of lifestyle changes, but doesn't want to offend her or have her leave before he gets his message across.

Reply: This scenario brings up a very important issue that is encountered in everyday practice -- how to broach the subject of obesity and unhealthy lifestyle behaviors with our patients. Dr. Elliot's fear of offending Lang is primarily based on the social stigma and shame surrounding being overweight or obese. He may be worried about starting this discussion during an office visit with strict time constraints and think he has less than optimal level of knowledge and confidence in managing obesity.

Yet Dr. Elliot correctly views Lang's weight as an important health issue. It would be unhelpful, and perhaps dangerous, to adopt a "don't ask, don't tell" understanding with Lang about her weight because of the significant morbidity associated with obesity. Dr. Elliot should engage Lang in a discussion using an empathic tone and incorporating the following communication strategies to help him feel more comfortable discussing the problem.

Acknowledge the patient's chief complaint, independent of weight. Even if it is obvious that the patient's presenting conditions are related to weight, remember that chief complaints are always defined by patients themselves. Listen to and explore the patient's chief complaint, including his or her impression of the underlying causes, without focusing on obesity. The topic of weight should be brought up after the patient's concerns are discussed.

Assume the obese patient knows he or she is overweight. Most overweight and obese individuals are already aware that they have excess weight, although they might not necessarily understand how this will affect their health. Rather than telling patients that they are overweight and exploring their reactions to this statement, it is better to focus on how a patient's weight affects his or her health.

For example, instead of asking your patients, "Do you know you weigh too much?" it is more constructive to say, "I'm concerned about your weight because I think it's causing health problems for you. Do you think your weight is causing problems for you?" This is especially important when being overweight contributes to other chronic diseases.

Base the discussion on your patient's readiness. Patients are more likely to engage in discussions that are tailored to their stage of readiness to discuss their weight and their understanding of how being overweight may affect their health. For example, patients who do not believe that their weight is problematic are unlikely to listen to recommendations to lose weight through dietary management and physical activity. It may be more productive to focus on educating these patients about health risks associated with overweight and obesity.

Offer unconditional acceptance. Because many overweight individuals encounter bias, they may fear their physician's disapproval. Doctors should acknowledge that weight management is a challenge and offer praise for any effort the patient has made, regardless of its success.

If patients acknowledge a concern about their weight, the following questions may help to engage the patient in a dialogue about weight management.

What is hard about managing your weight? This open-ended empathic question acknowledges that weight control is difficult and conveys the physician's interest in gaining a further understanding from the patient's perspective.

How does being overweight affect you? This question probes the burden of obesity. Common answers refer to appearance, self-esteem and image, physical ailments, and quality of life.

What can't you do now that you would like to do if you weighed less? This question provides useful information regarding expectations and benchmarks for assessing progress.

What would you like to get out of this visit regarding your weight? This directly addresses patients' expectations related to how the physician can assist them in weight management.

Robert F. Kushner, MD, professor of medicine, Northwestern University Feinberg School of Medicine; director, Wellness Institute at Northwestern Memorial Hospital

For information on providing obesity care in the office, read the American Medical Association's Assessment and Management of Adult Obesity: A Primer for Physicians, available online (link).