The Elephant in the Treatment Room

Domestic abuse can be the "elephant in the treatment room."

Risk Management

The Elephant in the Treatment Room

You've been treating a patient for a disc problem for the past few months. She had a fractured collarbone about six months prior, but nothing in the history otherwise stands out. The patient has made significant clinical improvements and seems content overall with the care provided. Sure, she's not exactly a conversationalist and you sense she is holding something back, but that's no reason for you to be concerned ... right?


Of course, there several reasons a patient could be less than warm and friendly, including his or her personality. But consider the possibility that unbeknownst to you, the patient's spouse is stewing behind the scenes, and your patient fears being beaten.

While not every "unusual" patient will be a victim, domestic abuse can be the "elephant in the treatment room" that no one wants to talk about. However, as a D.C., it is something you must consider if you suspect something is amiss, especially if you observe or there is a history of bruises and fractures.

Physical and sexual violence by an intimate partner are common problems, affecting 20 to 50 percent of women at some stage in life.1

Domestic abuse also can be life-threatening. On average, more than three women are murdered by their husbands or boyfriends in this country every day. In 2000, 1,247 women were killed by a domestic partner. The same year, 440 men were killed.2

As a result, it is important to pay attention to your instincts when you have a patient that may be a domestic abuse victim. Here are some strategies to help identify potential victims:

Be Specific with Your Questions and Listen

If you fail to inquire about the situation or disregard responses that point to abuse, the patient may perceive that you place little importance on his or her health and welfare.

Watch for Verbal and Nonverbal Cues

  • Verbal cues that signify undue influence by a spouse. For example, a patient who repeatedly voices comments like: "My husband always says ..." or who indicates her husband is waiting in the car because "He doesn't trust me."
  • Body language, such as poor eye contact and nervousness.

Listen for Changing or Evolving Histories

Be alert to signs of injury or that there's been a delay in seeking care. Thoroughly document everything that's said when taking the history.

Look for Multiple Bruises

Multiple bruises in various stages of healing can point to an ongoing pattern of injury.

Be Suspicious of Fractures

High specificity for abuse:

  • Multiple fractures in various stages of healing
  • Metaphyseal "chip" or "bucket-handle" fractures
  • Posterior rib fractures or first rib fractures
  • Scapula fractures
  • Spinous process fractures
  • Sternal fractures

Moderate specificity for abuse:

  • Multiple or bilateral fractures
  • Epiphyseal separation 
  • Vertebral body fractures 
  • Digit fractures 
  • Complex skull fractures

What if You Suspect Something?

If it crosses your mind that a patient could be a victim of abuse, heed that instinct. Your patient won't necessarily perceive it as a serious issue and may not feel comfortable bringing up the subject. Instead, a patient may tend to view it as a side issue to drug abuse, alcoholism, poor communication, depression or marital stress. Consequently, a victim will tend to make excuses for the abuser such as "He only hits me when he's had too much to drink" or "She only acts this way when she's high."

In these situations, it is critical to educate yourself and your staff regarding community resources for your patients. You may wish to advise the patient to:

  • Know the domestic abuse hotline number, 800-799-SAFE
  • Keep emergency money, as well as an extra set of car keys hidden in a safe place
  • Confide in a close friend and arrange to call that person in an emergency, prearranging a code word to indicate an emergency 
  • Obtain a cell phone, if possible

At the same time, remember, as a D.C., you are not a licensed therapist and need to be careful with professional licensure lines. While it's normal to want to help, guard against becoming overly involved in the situation.

Many doctors have become frustrated when a patient fails to get out of a clearly bad situation. Others have run afoul with patient confidentiality laws when they revealed protected information in an attempt to get the patient help.

Most important, comply with your state law requirements for reporting domestic abuse. Contact your state licensing board, state association or NCMIC's Claims Advice Hotline, 800-242-4052, for guidance.

While the example shown is of a female patient, it could have also been a male.

1. Heise L, Ellsberg M, Gottemoeller M. Ending violence against women. Baltimore: Center for Communication Programs, Johns Hopkins School of Public Health, 1999.

2. Bureau of Justice Statistics Crime Data Brief, Intimate Partner Violence, 1993-2001, February 2003.

3. Strauss, Murray A, Gelles, Richard J, and Smith, Christine. 1990 Physician Violence in American Families; Risk Factors and Adaptations to Violence in 8,145 Families. New Brunswick: Transaction Publishers.

4. National Clearinghouse on Child Abuse and Neglect Information, a service of the Children's Bureau, Administration on Children, Youth and Families, Administration for Children and Families, U.S. Department of Health and Human Services. 


The information in the NCMIC Learning Center is offered solely for general information and educational purposes. It is not offered as, nor does it represent, legal or professional advice. Neither does this information constitute a guideline, practice parameter or standard of care. You should not act or rely upon this information without seeking the advice of an attorney familiar with the specific legal requirements of the state(s) in which you practice. If there is a discrepancy between the site and an insurance policy you have with NCMIC, the policy will prevail.