Addressing intimate partner violence in the surgical community: Is there a need?

In March 2017, the surgical community was shocked and saddened by the tragic death of Sherilyn A. Gordon, MD, FACS. She was killed in her Richmond, TX, home by her husband. Dr. Gordon was a well-regarded transplant surgeon at the Houston Methodist J.C. Walter Jr. Transplant Center and associate professor of surgery at Houston Methodist Hospital, TX, where she served as the general surgery residency program director, the assistant dean for graduate medical education (GME) at Texas A&M Health Science Center, and the first physician to serve as the designated institutional official for GME at Houston Methodist Hospital.

Her death’s impact on her family, friends, and colleagues led her close personal friends and two authors of this article—Barbara Lee Bass, MD, FACS, President, American College of Surgeons (ACS), and Patricia L. Turner, MD, FACS, Director, ACS Division of Member Services—to reflect on the prevalence of this issue in the surgical community, particularly against the backdrop of a seeming increase in the frequency of stories about physicians killed, stalked, or injured as reflected in the lay press. They began to consider what the ACS should do to address and prevent intimate partner violence (IPV) within the surgical community. Because IPV is often “hidden behind closed doors,” one of the elements of Dr. Bass’s Presidential platform was to convene an ACS IPV Task Force in January 2018.

What is IPV?

According to the Centers for Disease Control and Prevention (CDC), IPV is a significant and preventable public health problem that affects millions of Americans. The term “intimate partner violence” describes physical violence, sexual violence, stalking, and psychological aggression (including coercive acts) by a current or former intimate partner.

An intimate partner is a person with whom one has a close personal relationship that can be characterized by the following:

• Emotional connectedness
• Regular contact
• Ongoing physical contact and/or sexual behavior
• Identity as a couple
• Familiarity and knowledge about each other’s lives

The relationship need not involve all these dimensions. Examples of intimate partners include present or former spouses, boyfriends/girlfriends, dating partners, significant others, or sexual partners. IPV can occur between heterosexual or same-sex dyads and does not require sexual intimacy.

IPV exists on a continuum of severity and may range from a single transient episode to chronic and severe episodes spanning years and engendering significant physical and psychological trauma.*

ACS IPV Task Force goals and objectives

The mission of the ACS IPV Task Force, co-chaired by Drs. Bass and Turner, is to raise awareness of the incidence of IPV in the surgical community; educate surgeons to recognize the signs and consequences of IPV in themselves and their colleagues; provide resources for survivors, including prevention and escape strategies; and create resources and curricula in partnership with other national professional and educational organizations to instruct surgeons about how to recognize IPV in colleagues and trainees.

The following core values inform the mission of the task force:

• Respect and compassion for ourselves and our colleagues
• Inclusion of all members of the surgical community through years of training and practice, regardless of sexual orientation, gender identity, age, socioeconomic status, training level, culture, religion, race, or ethnicity
• Support and understanding of individuals who are presented with life choices and challenges without clear solutions, including supporting those who remain in difficult situations

The task force has established the following goals and objectives to guide their efforts:

• Raise awareness about IPV in the surgical profession
• Establish the incidence of IPV among surgeons
• Develop strategies to support surgeons affected by IPV and to assist with referral to IPV support resources
• Establish educational programs for the surgical profession on how to identify and support survivors of IPV
• Develop peer-to-peer intervention training programs
• Develop an IPV survivor toolkit for use by surgical societies and surgical training programs
• Partner with other committees and organizations to develop primary prevention and intervention strategies

Raising awareness

An initial goal of the members of the task force was to advance their knowledge of the causes and incidence of IPV and to build awareness of the resources and data available in the U.S. In addition to learning about the work of the National Center on Domestic and Sexual Violence and the National Coalition Against Domestic Violence, the task force reviewed resources and toolkits provided by the CDC, the World Health Organization (WHO), and the New York City Domestic Violence Task Force, among other organizations. These resources assisted the task force in focusing their efforts moving forward, which will include creation of an awareness campaign to destigmatize the issue and to foster self-evaluation of personal risk and safety. The task force also seeks to create resources to assist colleagues who are survivors of IPV and to highlight educational content addressing IPV for use in medical school and residency program curricula, as well as to draw attention to other relevant programming to support the surgical community.

In May, Drs. Bass and Turner, and Susan Pories, MD, FACS, a member of the task force and Chair of the ACS Women in Surgery Committee (WiSC), traveled to New York, NY, to meet with representatives from the New York City Domestic Violence Task Force. The goal of the meeting was to gain input and advice on how the ACS can develop an awareness campaign and a comprehensive plan to address IPV in the surgical community. The New York City Domestic Violence Task Force was initiated by the Mayor’s Office to Combat Domestic Violence and was led by New York City’s First Lady, Chirlane Irene McCray.

In 2007, nearly 5 percent of all major crimes in New York were related to domestic violence. By 2016, that percentage had more than doubled to nearly 12 percent. IPV accounts for 20 percent of homicides and 40 percent of reported assaults citywide. New York’s efforts target four areas—expanding child and youth prevention and intervention, enhancing criminal justice responses, strengthening communities, and improving citywide coordination to maximize results.^†

Some of the relevant insights about IPV shared by the New York City Domestic Violence Task Force members included that the abuser often allows the victim to seek health care, a point of potential intervention by the patient care team. However, health care providers may not be equipped to effectively intervene when IPV victims present for care. Health care professionals often are unsure how to initiate a conversation about IPV or are unfamiliar with next steps if IPV is uncovered. Validated screening and assessment tools, conversation guides, and support intervention strategies can be important tools for the health care community to use. Furthermore, victims of IPV often feel shamed by their condition as a victim and are reluctant to admit their need for help or fear the consequences of seeking shelter or assistance because of concerns about their children, finances, or future escalated harm. Well-educated or prominent members of the community counterintuitively may find accessing resources quite difficult, as the stigma of victimization is personally and potentially professionally humiliating.

New ACS statement

One of the initial efforts of the task force to raise awareness among the membership was to review and update the ACS Statement on Intimate Partner Violence originally developed by the ACS Committee on Trauma (COT) in 2014. The Board of Regents, at its June meeting, approved the new statement, which was revised by the ACS Intimate Partner Violence Task Force and the ACS WiSC. In addition to replacing the 2014 statement, the new statement, published in this issue of the Bulletin, also replaces a Statement on Domestic Violence that the COT developed in 2000. ACS members are encouraged to share the updated statement with their colleagues, within their departments of surgery, and with their respective professional organizations.

Assessment

To understand the level of awareness, incidence, and educational needs of surgeons as they relate to IPV, the task force has developed a brief survey that will be deployed to ACS members by the end of 2018. The task force will analyze the survey data and use this information to determine the specific types of resources that could be of value to members of the surgical community.

Diana Lautenberger, MAT, director of women in medicine and science for the Association of American Medical Colleges (AAMC), serves on the ACS IPV Task Force, and is leading a similar effort within the AAMC. To address the need to increase IPV awareness in medical students, the task force is working with Ms. Lautenberger to add relevant questions to the AAMC’s annual medical school graduation questionnaire and into the Liaison Committee on Medical Education’s annual medical school questionnaire.

Education

Initial efforts to enhance the knowledge of ACS membership about IPV will be included in the 2018 Clinical Congress, October 21–25 in Boston, MA, with a Town Hall session Tuesday, October 23, from 7:00 to 7:45 am. Drs. Bass and Carrie A. Sims, MD, PhD, FACS, a member of the task force, will lead a discussion titled Addressing Intimate Partner Violence for the Surgical Community. Additional panel sessions have been proposed for the 2019 Clinical Congress, along with presentations at the Medical Student and Resident Day programs that take place at the meeting.

The task force will develop a multipronged educational strategy, including educational programming for all levels of the membership incorporating webinars, online training programs, chapter presentations, and Clinical Congress sessions. October is Domestic Violence Awareness Month, and the IPV Task Force will spearhead a recognition effort at this year’s Clinical Congress, providing IPV ribbons for attendees to raise awareness.

Prevention and intervention

The task force is finalizing a tool kit for surgeons that will be available later this year and which will include the following content:

• What is IPV?
• Who is at risk for IPV?
• What are the laws regarding IPV?
• How do I recognize if my colleague is experiencing IPV?
• How do I recognize if my patient is experiencing IPV? (including guidance on how to identify current violence, assess any history of violence, identify signs and symptoms of distress and violence, and address denial of suspected abuse).
• How do I recognize if I am experiencing IPV?
• How do I determine if I am in danger?
• How can I get help?
• Planning for safety.
• What do I take when I leave?
• Information about accessing resources, including the National Domestic Violence Hotline.

The task force anticipates that the development and dissemination of these resources will create a new level of awareness within the surgical community and provide surgeons with the tools they need to have those critical conversations with their colleagues, as well as to assess themselves, to prevent future occurrences of IPV that have become much more prevalent today. The task force will continue to release additional resources in the coming year and will be working to build partnerships and explore additional opportunities for collaboration with other surgical societies interested in contributing to this effort.

*Breiding M, Basile K, Smith S, Black M, Mahendra R. Intimate Partner Violence Surveillance Uniform Definitions and Recommended Data Elements Version 2.0. Centers for Disease Control and Prevention National Center for Injury Prevention and Control; 2015. Available at: www.cdc.gov/violenceprevention/pdf/intimatepartnerviolence.pdf. Accessed August 27, 2018.

^†NYC Domestic Violence Task Force 2017 goals and recommendations. NYC Mayor’s Office to Combat Domestic Violence. Available at: www1.nyc.gov/assets/ocdv/downloads/pdf/DVTF-2017-Recommendations.pdf. Accessed September 21, 2018.