Oral History Theme: Orthopaedic

surgeons’ misperceptions

”The main thing that we have to do is convince surgeons that this is not a

problem of other groups; this is an issue that we are dealing with every single

day in our clinics. […] I had to convince surgeons, quite frankly, that their perceptions about IPV are in fact

gross misrepresentations, if not misperceptions, based on the reality of

the situation.” – Mohit Bhandari8

BACKGROUND

METHODS

RESULTS CONCLUSIONS

Ø Oral history interviews with orthopaedic surgeons who have led efforts to improve IPV awareness, response, and advocacy in their specialty: Ø Dr. Mohit Bhandari, M.D., McMaster Univ. Ø Dr. Debra Zillmer, M.D., Mayo Clinic

Ø Primary and secondary literature reviews and analyses

Ø Research in the historical archive at the Futures Without Violence nonprofit organization in San Francisco, California

How did Intimate Partner Violence (IPV) evolve into an orthopaedic medical issue? Historical perspective on

IPV in orthopaedic surgery Brent C. Pottenger, M.H.A., M.S.II

Johns Hopkins University School of Medicine, Baltimore, Maryland, USA

What society defines as a medical issue changes over time. Medicalization of numerous behaviors and social problems was a characteristic of the twentieth century in the United States, expanding the scope of healthcare significantly.

Medicalization transforms healthcare by redefining expectations of and practices by medical professionals. It changes physicians’ roles in society and their clinical responsibilities.

Understanding how Intimate Partner Violence (IPV) came to be understood as a medical issue, including an appreciation for the historical context amidst which this occurred, can help inform care by identifying themes that shape clinical practice, such as standardization versus individualization.

Purpose: This project aims to understand how care for Intimate Partner Violence (IPV) victims evolved into an orthopaedic medical issue through clinical, professional, social, and cultural change.

Medicalization of violence: “[I]n the past fifty years […] the jurisdiction of medicine has grown to include new problems that previously were not deemed to fall within the medical sphere.” - Peter Conrad1

Evolving physician attitudes: “The attitudes of physicians are, of course, subject to the characterizations of woman abuse arising from broader societal attitudes and beliefs concerning the sanctity and privacy of family, women’s role and position in society, male privilege, and public tolerance of abuse.” – Marilynne Bell and Janet Mosher2

Standardization vs. individualization of care: “First, it is clear that protocols—even those that resist medicalization, and so on—will not effect much positive change in the hands of a person unskilled in using them. Thus, a crucial piece of work to be done is the ‘skilling’ of physicians.” – Marilynne Bell and Janet Mosher2

This history of the medicalization of IPV in orthopaedics illustrates the close interrelationship between medicine and society and how particular health problems first gain recognition and then shape healthcare policies and practices. Understanding the process by which social issues like IPV evolve into medical issues aids our understanding of the role that medicine plays in society and what we should expect of its professionals, such as orthopaedic surgeons. The scope of medical practice changes over time as a result of cultural and social forces influences on both patients’ and healthcare professionals’ perceptions of health and medicine.

Until the 1970s, IPV was a nonmedical issue. Starting in the 1970s, “wife battering” (thereafter termed “domestic violence” and then “intimate partner violence”) emerged as a major social and then public health issue:

Ø  Terminology Evolution: (1) Wife Battering à(2) Domestic Violence à (3) Intimate Partner Violence

This emergence of IPV as a social, health, and finally medical issue occurred amidst the backgrounds and subsequent fallouts of the civil rights, feminist, and patients’ rights movements. The confluence of these social, cultural, and political forces shaped how both patients and physicians think about IPV and, in response, changed how medical professionals respond to this issue.

How IPV evolved into an orthopaedic medical issue:

Ø  (1) Cultural awareness of IPV as a social issue à (2) Recognition of IPV as a health issue à (3) Creation of specialty-specific patient care policies and practices, as occurred in orthopaedic surgery.

Oral History Theme: IPV protocols lacking in orthopedics

”With elder and child abuse, it’s quite

easy: you find your state statute on responsibilities and reporting and

follow the guidelines. But what to do for a victim of IPV is not well defined or regulated unless there has been gun violence or life threatening injury. We are therefore left on our own to decide what to do. Becoming educated on this

very relevant orthopaedic topic can serve to guide us.” – Debra Zillmer7

BIBLIOGRAPHY

1. Conrad P. The medicalization of society: on the transformation of human conditions into treatable disorders. Johns Hopkins University Press: Baltimore, 2007. 2. Bell M, Mosher J. (Re)fashioning medicine's response to wife abuse. Susan Sherwin, ed., The Politics of Women's Health (1998): 205-234. 3. http://www.learningradiology.com/caseofweek/caseoftheweekpix2/cow157lg.jpg 4. http://www.mayoclinic.org/images-biophotos/15419762.jpg 5. http://fhs.mcmaster.ca/sackettsymposium/images/bhandarimohit.jpg 6. http://www.futureswithoutviolence.org/ 7. Zillmer, Debra. Personal interview. July 2012. 8. Bhandari, Mohit. Personal interview. July 2012. 9. Akbarnia B, Torg JS, Kirkpatrick J, Sussman S. Manifestations of the battered-child syndrome. J Bone Joint Surg Am. 1974 Sep;56(6):1159-66. 10. Varvaro FF, Lasko DL. Physical abuse as cause of injury in women: information for orthopaedic nurses. Orthop Nurs. 1993 Jan-Feb;12(1):37-41. 11. Zillmer DA. Domestic violence: the role of the orthopaedic surgeon in identification and treatment. J Am Acad Orthop Surg. 2000 Mar-Apr;8(2):91-6. 12. Bhandari M, Dosanjh S, Tornetta P 3rd, Matthews D; Violence Against Women Health Research Collaborative. Musculoskeletal manifestations of physical abuse after intimate partner violence. J Trauma. 2006 Dec;61(6):1473-9. 13. Bhandari M, Sprague S, Tornetta P 3rd, D'Aurora V, Schemitsch E, Shearer H, Brink O, Mathews D, Dosanjh S; Violence Against Women Health Research Collaborative. (Mis)perceptions about intimate partner violence in women presenting for orthopaedic care: a survey of Canadian orthopaedic surgeons. J Bone Joint Surg Am. 2008 Jul;90(7):1590-7. 14. Bhandari M, Sprague S, Dosanjh S, Petrisor B, Resendes S, Madden K, Schemitsch EH; P.R.A.I.S.E. Investigators. The prevalence of intimate partner violence across orthopaedic fracture clinics in Ontario. J Bone Joint Surg Am. 2011 Jan 19;93(2):132-41. Epub 2010 Dec 10. 15. Koop CE,Senate Committee on Labor and Human Resources United States. Domestic Violence and Public Health - Hearing Before the Senate Subcommittee on Children, Family, Drugs and Alcoholism, October 30, 1985. National Institute of Justice. 30 October 1985. 16. http://demos.biemedia.com/omp-demos/www.itriagehealth.com/disease/clavicle-fracture-(broken-collar-bone).html *Special thanks to Nathaniel Comfort (Department of the History of Medicine) for his mentorship on this project.

Dr. Mohit Bhandari, MD5

Dr. Debra Zillmer, MD4

Photo credit: Brent Pottenger, Baltimore, MD, 2012

X-ray: IPV victims suffer fractures3

Net Result: Silence on

Intimate Partner Violence

Misperceptions: Not an

orthopaedic issue

Misconceptions: Not prevalent in

orthopaedic practice

Misinformation: Not prepared to

respond appropriately

Net Result: Improved

patient care for IPV victims

Collaborate: Partner with nurses to screen for and respond to IPV

patients

Communicate: Study, publish, and present to

various audiences about IPV care in

orthopaedics

Advocate: Work with orthopaedic organizations to influence policies

and practices

Educate: Provide /create specialty

specific resources for surgeons to fill knowledge gaps; implement IPV

training in medical school and

residency training

Logo: First family violence nonprofit organization formed in 1980 in San Francisco, California6

Department of the History of Medicine

Photo: Justice problem or public health problem? Billboard (c1980s) still standing in East Baltimore, Maryland reflects how older conceptions of IPV still permeate our culture

Figure 1. Medical silence on IPV stems from lack of understanding and communication:

Figure 2. How to break the silence on IPV in orthopaedic surgery:

Oral History Theme: Medicalization of IPV still contested “I remember one person saying, ‘This is opening a can of worms that we may not want to get into right now.’ That was the debate. There was a considerable degree of concern and worry that this really isn’t our issue and

why are we delving into something that’s really more a social services issue than a surgical issue.” – Mohit Bhandari8

Timeline: Historical events in the medicalization of IPV