I long for a world where when I listen to patients tell me about their lives, I don’t have to subtly check them for bruising.
I catch myself doing it; so keen to maintain rapport and show empathy by maintaining eye contact, I sneak what chances I can to glance at exposed parts of the body, particularly the wrists and the upper arms. Experience has taught me that the markers of domestic violence, both physical and mental, are almost always hidden with an unfortunate, practised skill. Those who suffer it over time become experts in misdirection and alternative explanation.
I have had to learn from mournful experience that domestic violence cuts across all social factors and remains, despite increasing awareness and campaigning, a shameful constant of our society. It matters not what someone’s job is, their background, how educated they are, or where they live.
While cultural and legal frameworks have changed, domestic violence has been present throughout time. It respects no boundaries; it appears to be a disease of humanity.
Within our supposedly civilised society here in the UK, a woman is killed by their partner every three days. In the time between each episode of Strictly Come Dancing there are two women no longer alive because their partners (or ex-partners) have killed them. It is so commonplace that this no longer even registers as news. More unborn children are harmed by violence, than by gestational diabetes or pre-eclampsia.
I’m a human and I want to see a world where domestic violence doesn’t happen, and if it does, I want those responsible to be severely punished. I want to see society rail against this, not accept it as a norm.
But I’m a GP too, and GPs have to live in the real world. I must accept that this is how things are and I have my part to play in dealing with it. As with most things in general practice, that is both a wonderful privilege and a frightening responsibility.
So how do I see my role? I need to have awareness and constant suspicion – which is draining and depressing, but vital – and I need to know my subject. I haven’t learned about domestic violence from books, or from training sessions. I have learned from my patients, my trainers and colleagues, and from my experiences.
I have to remember that while it is usually men doing this to women, relationship violence is pervasive: women, men, same-sex relationships, families and children are all affected and the perpetrator can be anyone, even a doctor. “But he seemed so normal, so … nice,” just doesn’t cut it. And there is, of course, so much more to domestic abuse than the extremes of violence.
I must avoid professional denial, which can be so damaging, and the temptation to accept a patient’s excuse or explanation. I must use all my skills to demonstrate empathy.
Over the minutes and years I must build sufficient therapeutic rapport with my patients so that, if today is the day that they might admit it to someone and ask for help, I make that possible. I may only get one chance with my patient and I don’t know when that chance is coming. So I must give the impression I have time even when I might not, and I must listen and watch for the clues, verbal and non-verbal, which might be so subtle as to hardly be there. The patient must feel they can tell me anything and that I won’t judge or betray. They must trust me. And I must try to be their expert friend.
I need to be brave enough to ask the easy and the difficult questions: “How are things at home?”, “How are things with you and your partner?”, “Do you feel safe?”, “Has your partner ever hurt you?” If I haven’t built sufficient rapport, then these questions are pointless, but I never said this was easy.
I must deal with the fact that I may have to care for the perpetrators of violence. That the very person who has beaten the patient I see one day, may be my patient the next. I must manage with professionalism the conflict and emotion that this brings.
Finally, I have to familiarise myself with the support available for my patient, nationally and locally. They need to know that if they disclose this to me not only can I be trusted, but also I actually know what to do. I can help.
This is society’s problem – in my opinion one of its greatest – and solutions must come at that level. But while I feel powerless, maybe I can be a small part of the solution. The privilege, the responsibility. This is general practice. Yes, I long for a world without bruises, but for now I’ve got a job to do.
Dr Dom Patterson tweets at @DocDomP
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