Module 3: Training Materials (health sector)

Mr. Thompson, an 80-year-old widower, sought medical attention for anxiety and signs of depression.

Dr. Miller: Good morning, Mr. Thompson. How are you feeling today?

Mr. Thompson: Oh, you know, just the usual aches and pains that come with age. Nothing much to worry about.

Dr. Miller: I understand. But I’m here to help with any concerns you might have. Anything on your mind that you’d like to discuss?

Mr. Thompson: Well, doc, it’s not just the physical stuff. I’ve been feeling down and tired lately.

Dr. Miller: I appreciate your openness, Mr. Thompson. Let’s talk about anything that might additionally be on your mind. Besides the physical discomfort, have there been any changes in your life or relationships that might be affecting your well-being?

Mr. Thompson: (hesitant) It’s… it’s not easy to talk about. But it’s Jessica, my caregiver. Things haven’t been great.

Dr. Miller: It takes courage to discuss difficult situations. Can you share more about what’s been happening?

Mr. Thompson: She gets angry a lot, and there are hurtful words. I feel like I’m walking on eggshells, you know?

Dr. Miller: I’m sorry to hear that, Mr. Thompson. It sounds challenging. Can you share more about how it’s affecting you?

Mr. Thompson: (guarded) It’s affecting my sleep, my mood. I feel trapped in my own home.

Dr. Miller: Thank you for trusting me with this information.

Mr. Thompson: I just want it to stop, doc. It’s affecting my health, both physically and mentally.

Dr. Miller: I hear you, and I’m here to help. We can work together to address these concerns. If you’re comfortable, we may need to involve others to support you.

Mr. Thompson: Thank you, doc. I… I didn’t know if I should say anything. It’s just been hard. I didn’t know where else to turn.

Dr. Miller: You’re not alone in this, Mr. Thompson. We’ll take steps to ensure your safety and well-being, involving the right people to support you through this difficult situation.

Task for reflection

(1) Examine the role of trust-building in this case study. How did Dr. Miller establish trust with Mr. Thompson, considering the sensitive nature of the situation? Reflect on strategies for building trust in challenging and vulnerable circumstances.

(2) Identify specific cues Mr. Thompson gave during the consultation that hinted at potential domestic violence. How did Dr. Miller recognise and interpret these cues?

See also Module 2 for possible indicators of DV against the elderly.  

Below is an example of a positive patient-staff interaction. The scene presented here is between Claire, a transgender woman, and Danielle, a front desk receptionist.

Danielle: Good afternoon. How may I help you?

Claire: Hello. I have an appointment with Dr. Brown at 2:30.

Danielle: Your name please?

Claire: Claire Brooks.

Danielle: I’m sorry but I don’t have you listed here. Might your appointment be under a different name?

Claire: Oh yes. I changed my name recently from Lawrence to Claire.

Danielle: Okay, I see here that the appointment is under Lawrence Brooks. I’m sorry for the mistake. I will update our registration system right away with your correct name.

Just to be sure we are using the right records; would you be able to tell me your birth date?

Claire: November 12, 1987.

Danielle: Great. And have you changed your name on your insurance?

Claire: No I have not.

Danielle: Okay, thank you. Just so you know, I won’t be able to change the name on your insurance for you. However, we have a case manager here who helps people with insurance and legal needs. Do you want me to get you in contact with her?

Claire: Oh yes, that would be great. Thank you.

Danielle: Sure thing.

Task for reflection

(1) In this scenario, Danielle uses several communication strategies with Claire. Can you identify what they are?

Case and task for reflection from: National LGBTQIA+ Health Education Centre, “Affirmative Services for Transgender and Gender-Diverse People – Best Practices for Frontline Health Care Staff”, 2020, p. 7, https://www.lgbtqiahealtheducation.org/publication/affirmative-services-for-transgender-and-gender-diverse-people-best-practices-for-frontline-health-care-staff/, accessed 11.02.2024.

A 19-year-old patient visits a family practice for a consultation.

Physician: “Good morning, what can I do for you today?”

Patient: “I feel totally overworked at the moment and wanted to ask if you could put me on sick leave for two weeks?”

Physician: “Is there any particular reason why you feel that way and has this happened before?”

Patient: “I have never been on sick leave because of overload before. But I recently moved out of my parents’ house in my own flat. Everything just gets too much for me at the moment.”

Physician: “Of course, I can put you on sick leave, but if you feel so overwhelmed by your situation, I would be happy to offer you further support. Perhaps you would like to talk to me about it?”

Patient: “Mmm, I actually feel very uncomfortable to talk about it. There were some problems with my mother in the past. She is a control freak and constantly checked my cell phone. We were fighting whenever I wanted to meet with my friends or family. As a result, I became more and more isolated and the only company when leaving the house were my parents. My mother read messages from my friends before I had a chance to read them. I felt very bad that’s why I decided to move out. But I don’t know if that was the right decision.”

Physician: “If your mother controlled and bullied you so much, why do you think to move out was a mistake?”

Patient: “During the time living in my own flat now, my mother kept calling me and sending me messages. I feel under pressure by saying that she cannot live without me and will hurt herself if I don’t come back. I see her car in the parking lot all the time: while shopping, being at work or meeting my friends. I always have the feeling that she is around. Can that even be a coincidence? I have already met her many times because I felt so sorry for her, and I was afraid that she would really hurt herself.”

Task for reflection

(1) Reflect on the physician’s response to the patient’s initial request for sick leave. How did the physician show empathy, and what cues in the patient’s language indicated there might be an underlying issue?

(2) Consider the moment when the patient hesitated to talk about the problems in the relationship. How manage the physician to enhance trust and to create a safe space for the patient to share the experiences?

(3) Analyse the patient’s description of the relationship with the mother. What are the red flags or signs of potential domestic violence? (see also Module 2)

Robin has come to the Emergency room with a suspected fractured arm, cracked ribs and bruising around his neck.

Robin has seen the triage nurse. He told the nurse that his injuries are the result of a fall down the stairs in his flat. Because of the bruise marks around his neck, Dr Andersson is concerned that Robin may be a victim of domestic violence.

Robin: I feel like such a fool! I don’t know what happened, I just tripped at the top of the stairs. I will try to be more careful in the future. Will it take much time to get better?

Dr Andersson: Accidents happen, Robin. Let’s focus on getting you better. I’ve noticed you’ve been here a few times recently. Any particular reason?

Robin: I’m just very clumsy I suppose. I keep falling, you know?

Dr Andersson: But the bruising around your neck is a very unusual injury to sustain from a fall. It’s far more likely to have been caused by pressure being applied, perhaps from someone’s hands…? Is everything okay at home?

Robin: I don’t know what you’re suggesting but everything is just fine. Can you please just fix my arm and let me go home now?

Dr Andersson: I want to make sure you get the right care. Despite what you’re saying, I’m concerned about your injuries. Can you share more about what might be going on at home?

(Robin remains silent)

Dr Andersson: I’m here to help, Robin. If there’s something you’re not comfortable sharing, that’s okay. But it’s crucial for your well-being that we understand the full picture. Now, about these injuries, let’s figure out the best course of action for your recovery.

Robin: (begins to cry) You know, a new roommate moved in a couple of months ago. At first, it was just joking around, funny punches and all. But then it got worse, and he would hurt me. When he’s stressed from university, he takes it out on me. I think I might be depressed. I can’t talk to anyone; I’m scared and feel powerless.

Dr Andersson (pauses and gives Robin time to do so): I know this is difficult to talk about. I appreciate you sharing that, Robin. It’s not easy. You don’t have to go through this alone. It is not ok that your roommate is hurting you and you are afraid of him. It’s essential to address both your physical injuries and emotional well-being. I am really concerned about your safety and would like you to speak with a victim protection group or a specialised NGO.

Task for reflection

(1) Assess the doctor’s communication skills in this scenario. What techniques did Dr Andersson use to encourage Robin to open up about his situation? How can effective communication play a pivotal role in cases of potential violence?
(2) Consider the cues that raised Dr. Andersson’s concerns about domestic violence. How did the doctor navigate this delicate situation while respecting Robin’s initial reluctance to share details?
(3) Evaluate Dr. Andersson’s communication strategy. How did the doctor manage to persist in getting information about Robin’s injuries while being sensitive to his emotional state?

Case adapted from General Medical Council 2023

Mrs. Miller presents as a new patient at a dental practice. She comes in because of persistent toothache in her upper jaw. The dentist immediately notices the patient’s anxious and timid behaviour. Although the patient has already filled out a medical history form in the waiting room, the dentist takes a moment to get to know the patient better.

Dentist: “Have you recently moved to K., Mrs Miller?” 

Mrs Miller: “No, my husband and I have lived here for seven years. I haven’t had any problems with my teeth yet. But now my toothache is giving me such sleepless nights that it’s unbearable.”

Dentist: “OK, then I’ll take a closer look”. At the start of treatment, the dentist recognises a small reddish haemorrhage around the patient’s eyes.

When she tries to look into Mrs Miller´s mouth with her mirror, the patient immediately flinches away. “I’m being very careful,” she says to the patient. “I’m just trying to get an overview to understand where the pain could be coming from”.

Mrs Miller nods, but her body does not relax. The cramped posture remains. When Mrs Miller is startled during the examination, her scarf slips and the dentist sees several dark purple and already faded haematomas at her neck. The dentist notices it, but doesn’t give it a second thought.

As the dentist cannot see where the toothache is coming from during the examination, she orders an X-ray. “Is that really necessary?” asks Mrs Miller. “Yes, definitely,” replies the dentist. “This is your first visit today. I would like to get an overview. Root tips and possible inflammation can only be diagnosed with an X-ray. To do this, I would like to take an overview image (OPG/PSA) showing all the teeth, the jaws and both temporomandibular joints. Furthermore, I cannot clearly see from the external examination where exactly your pain is coming from, i.e. from which tooth. Unfortunately, I can’t help you without having more Information. An X-ray is not painful at all. The machine only goes around you once!”.

When the dentist sees the x-ray, she is shocked. She recognises a fracture of the lower jaw on the x-ray. She wonders why Mrs Miller didn’t come earlier. That must have been hellish pain. When Mrs Miller is back in her treatment chair, the dentist mentions the broken jaw.

Dentist: “I can see a fresh fracture of the lower jaw on the x-ray, which may be responsible for the pain. Do you remember how this injury occurred?”

Mrs. Miller replies: “Oh, that was a long time ago. I can’t really remember it anymore.”

Dentist: “Is everything fine at home? Such injuries often occur when someone has been hurt by someone. Was that the case with you? I also saw several bruises on your neck.”

Mrs. Miller´s eyes fill with tears, but she doesn’t answer the questions. The dentist respects this and doesn’t want to put pressure on her.

At the end of the treatment, however, the dentist gives her a sort of a business card with the hidden numbers of women’s shelters and violence hotlines and explains that she can go there if something at home frightens her or she doesn’t feel safe any longer. She is also welcome to get in touch with her, too in case of need and tells her that nobody is allowed to hurt or frighten another person.

The dentist promptly calls the patient back in to continue the treatment and makes a corresponding note in the patient’s file. She plans to speak to Mrs. Miller again about the situation at home.

Task for reflection

(1) What indicators can be identified in this case study that Mrs. Miller could be a victim of domestic violence?
(2) What type of questions did the dentist ask the patient – direct or indirect?
(3) What worries and fears might patients such as Mrs. Miller experience in the dental practice? What could prevent victims from disclosing the domestic violence they have experienced?
(4) How did the dentist react when Mrs Miller did not answer the questions about domestic violence?