Violence in America – Right Here in River City!

1. Violence in America – Right Here in River City! John C. Nelson, MD, MPH Former President, American Medical Association

2. Violence in America • Violence is a public health problem. • George D. Lundberg, MD, former editor of JAMA. • C. Everett Koop, MD, former US Surgeon General

3. The Practice of Medicine • The medical history: 85% • The physical examination: 10% • The clinical lab exam: 5%

4. The Practice of Medicine If you do not think of the diagnosis, you cannot make the diagnosis.

5. The Practice of Medicine Ethics Patient/Physician Relationship Science Caring

6. The Practice of Medicine • The patient/physician relationship is the cornerstone of American medicine and has been for over two centuries. • Extremely personal information is exchanged. • Diagnosis cannot be accurate if this relationship is jeopardized.

7. Anatomy of a Relationship Caring Dishonesty Respect Honesty A B Trust Loyalty Communication

8. The Practice of Medicine • Very important to be able to relate to patient and have the trust and confidence needed for a victim to share her situation. • A female victim of violence would rather speak to her physician than any other person.

9. Abuse is: Forceful, controlling behavior that coerces a person to do what the abuser wants without regard to her/his rights, body, or health.

10. Kinds of Violence • Spousal abuse. • Child abuse. • Elder abuse. • Sexual assault. • Violence in the media. • Verbal abuse/emotional. • Financial abuse.

11. In all kinds of violence, • The perpetrator attempts to control the actions of the victim. • The issue is never sexual, emotional, financial, or physical alone, it is about being in charge. • The goal is domination.

12. State of Utah 2006 Comparisons • DUI arrests: 9,878. • Drug offenses: 15,406. • Women experiencing domestic violence: 69,107. • (Source: CCJJ.)

13. In Utah (2006) • More than one in three women report having been a victim of some form of domestic violence. • Source: Dan Jones Survey Reports.

14. A female patient between the ages of 15 and 44 years is more likely to present herself to the ER because she is a victim of violence than for any other reason!

15. In Utah (2008) • 60 homicides. • 29 homicides attributed to domestic violence. • On average 1/3 to 1/2 of homicides are domestic violence related.

16. Etiology of Violence • Violence is a LEARNED behavior. • So then, where do people learn how to become violent?

17. The Media • Television. • Newspapers. • Magazines. • Video games. • The internet. • And, in real life, too.

18. Exposure to Media Violence • Most kids spend more time in front of the TV/computer than in the classroom. • By senior year in high school, the average child has seen over 200,000 acts of violence, often unresolved. • They have seen over 16,000 murders portrayed.

19. We are products of our environment. • Michael Rich, MD, Pediatrician at Harvard Medical School. • Concerned about the effects that the media might have on the developing brain of a child. • Decided to do an experiment.

20. The experiment • Connected kids ages 6-10 to an MRI. • Showed violent TV images (scenes from “Rocky.”) • Marked changes in the SHAPE of some parts of the brain. • Desensitization may be a physiological, not a psychological phenomenon!

21. Violence in the Media • The Hi-Fi Murders in Ogden, Utah, 1974. • Details: • “Magnum Force” viewed 22 times. • Carol Naisbitt was the wife of my Father’s medical partner.

22. Public Health Approach • Focus on prevention through health promotion. • Relies on science to identify and evaluate effective preventive strategies. • Is a complement to criminal justice. • Emphasizes changes in behavioral, social, and environmental factors that cause violence.

23. Public Health Approach • Surveillance – ongoing collection of data re: incidence, risk factors, etc. • Identifying causes. • Development and evaluation of programs of prevention. • Implementation and dissemination of the programs.

24. Public Health Approach • Kinds of prevention. • Tertiary. • Secondary. • Primary. • Primary is usually the most effective and the least costly.

25. Public Health Approach • Tertiary prevention – setting the bones, suturing the lacerations, etc. • Secondary prevention – calling off the attacker. • Primary prevention – not allowing the event to occur in the first place.

26. Telltale Signs of Violence • Marks that resemble hands or fingers. • History of multiple fractures. • Withdrawn personality. • Vague answers to direct questions.

27. Senior Issues • Remember that an older person may have trouble with a detailed history in any event. • Time may be distorted. • TIA’s. • Early dementia. • Listen carefully.

28. Clinical Pearls • Patient makes the appointment, but is cancelled by someone other than the patient. • Advanced stage of disease. • Overbearing significant other who answers questions directed to the patient.

29. Clinical Pearls • Change in demeanor that cannot be explained. • Patient that is unusually withdrawn. • Multiple bruises in various stages of healing. • Multiple fractures.

30. Clinical Pearls • Unexplained, usually multiple lesions found on parts of the body covered by normal clothing. • Multiple appointments for seemingly trivial matters. • Multiple physicians with no obvious pattern (ie., orthopedist for Fx’s, etc.)

31. Domestic Violence • Many reasons why victims do not leave. • Average number of attempts to leave is 8 before successful. • Average amount of time to leave is 3 years. • Each time leaving is attempted, the violence may escalate.

32. Exit Plan • Sometimes a patient will not be able to leave the abuser right away. • Needs to have a specific plan on how to escape in the event of renewed violence. • Needs to be well thought out in advance. • May not be feasible for a senior.

33. Reporting • Take away message: follow the law!

34. Our lives begin to end the day we become silent about things that matter. Martin Luther King

35. State Laws • Vary considerably. • If a person is harmed in front of a child, then there is an automatic additional charge of child abuse in Utah.

36. Elder Abuse • Encompasses physical, psychological, and economic mistreatment or neglect. • May be intentional or unintentional. • Caregivers can be pivotal in the detection, management, and prevention of elder abuse.

37. Special Concerns of Seniors • Trust is very important in relationship with senior patients, too. • Special circumstances: • Dependent on kids for place to stay. • Dependent on kids for transportation. • Dependent of kids for daily living, etc. • May be frightened to confide.

38. Special Concerns of Seniors • Where will the patient end up? • May not be able to care for self. • Nursing home is an expensive alternative. • Fear of loss of autonomy is real. • Heirs don’t want to spend their inheritance.

39. Special Concerns of Seniors • Abuser may be the caregiver or the one who oversees the caregiver. • Significant loss of autonomy has already occurred and could worsen. • The fiscal reality of the care may force less palatable choices.

40. Special Concerns of Seniors • Options for site of care are quite limited. • Often not able to drive. • Options are not well known by either the senior or the caregivers. • Whom can the senior trust?

41. Special Concerns of Seniors • The aging process itself. • Loss of memory. • Difficulty in processing data. • Variety of physical ailments. • Mobility issues. • Overall frailty. • Mental health issues.

42. Intervention • The best way to deal with the issue of senior abuse is to prevent it. • We need to be much more aware of the possibility than we are. • Health professionals need to be especially aware of the circumstances of each patient.

43. The most devastating plague of the 2oth Century is not AIDS, not Ebola virus, not drug abuse, and not violence. It is the plague of fatalism: the paralytic frame of mind that says that we cannot change the way things are, so why even try. William Foege, MD