Domestic abuse, patient coaching, and professional issues in obstetrics and gynecology

Recognizing domestic abuse

Federal law requires many insurance plans to cover certain preventive health services - including screening and counseling for interpersonal and domestic violence - without any cost-sharing for the patient, which is why this screening is a routine, no-cost part of every visit rather than something a patient has to seek out separately. Working in healthcare gives us an opportunity to provide support and resources for someone who is dealing with domestic violence. As a medical assistant, you should be looking for possible signs of abuse, such as the following:

• Unusual or frequent bruises or fractures
• Attempts to hide the bruises with makeup or clothing
• Low self-esteem
• Being extremely apologetic and meek
• References to the partner’s temper

If you notice any of these signs, you should make the provider aware of them. Even a patient who shows no signs of abuse should be asked if he or she feels safe in the home.

Scope of practice: A medical assistant’s role with suspected abuse is to observe, document objectively, and notify the provider - not to make an independent diagnosis or decide on a course of action. Whether a situation triggers mandatory reporting is governed by state law, not by the medical assistant’s own judgment.

The healthcare facility should put together a list of resources for patients who may be victims of domestic abuse. Having a list of shelters, advocacy groups, emergency contact phone numbers, and transportation services to give patients may provide them with the resources they need to make the decision to leave the abusive situation.

Abuse does not just happen in marriages or committed relationships; it can also occur in a dating relationship. We should be observing all patients for possible signs of abuse. Here are three national helplines with websites that patients could be referred to:

• National domestic violence hotline

  • Phone: 800-799-SAFE (7233)
  • Website: National Domestic Violence Hotline

• National dating abuse helpline

  • Phone: 866-331-9474
  • Website: Love Is Respect

• Office on women’s health

  • Website: Relationships and Safety Resources

Patient coaching

A woman who is planning a pregnancy or who has just found out that she is pregnant may benefit from some simple guidelines for healthy living:

• Nutrition: Before pregnancy, emphasize the need for folic acid to prevent neural tube defects. The woman can take a supplement or eat dark green, leafy vegetables. Many women have iron-deficiency anemia, and eating foods high in iron (red meat, spinach, or enriched cereal) is helpful. A pregnant woman must meet the calcium needs of both herself and her fetus; therefore, she needs about 1000 mg of calcium a day. Most pregnant women should consume about 1800 calories per day during the first trimester, 2200 per day during the second trimester, and 2400 calories per day during the third trimester. Women of average weight should gain 25 to 35 pounds, but underweight women should gain 28 to 40 pounds for a healthy infant.
• Alcohol: Alcohol passes through the placenta to the fetus and can cause serious problems. No one knows how much is safe, so it is a good idea for pregnant women to avoid alcohol completely.
• Smoking: Smoking can cause premature birth and low-birth-weight full-term infants. Smoking is linked to an increased risk of otitis media, heart problems, upper respiratory infection in infants, and also sudden infant death syndrome (SIDS). Pregnant women should not smoke and should not be exposed to secondhand smoke.
• Medicine: All chemicals pass through the placenta; therefore, a pregnant woman should never take any medicine (even over-the-counter drugs) without the knowledge and approval of her provider. If the medical assistant is managing telephone screening, having a list of provider-approved medications next to the phone helps answer patients’ questions.
• STI screening: STI screening should be done before a woman becomes pregnant. Many STIs are asymptomatic in women but treatable. Infants are at risk for serious health problems if exposed to certain STIs in utero or during the birth process.

Key point: Two of these rules come up most often: a pregnant patient should never take any medication, including over-the-counter drugs, without provider approval, and she should avoid alcohol completely, since no safe amount during pregnancy has been established.

Example: OTC medication during pregnancy

A pregnant patient calls asking whether she can take an over-the-counter antihistamine. As the medical assistant, you check the practice’s list of provider-approved medications; if it isn’t listed, you tell her you need to check with the provider first - you never approve or deny an OTC medication on your own.

Legal and ethical issues

Many ethical and legal issues arise as a result of missed communication. Listen to what every patient reports and write down any information that will assist the provider in treating the patient. The issue may appear to be an insignificant problem, but to the patient, it may be a major concern. Let the provider be the judge of whether the problem is relevant. As the patient’s advocate and the provider’s assistant, the medical assistant plays an important role in establishing good communication as a vital link in patient care.

Confidentiality is crucial in dealing with obstetric and gynecologic disorders. Only healthcare professionals directly involved in the patient’s care should know the purpose of the patient’s visit, diagnosis, or treatment. Maintaining patient confidentiality is not just an ethical responsibility; it is a legal requirement.

Patient-centered care

When providing patient-centered care while working in obstetrics and gynecology, a medical assistant should do the following:

• Behave in a professional manner at all times because an OB/GYN visit can be an uncomfortable and embarrassing situation for the patient.
• During patient education sessions, make sure that the patient truly understands the content.
• Stay current with the new topics and technology related to obstetrics and gynecology.
• Treat all patients as you would want to be treated.

Professional behaviors

When working in obstetrics and gynecology, it is important to remain nonjudgmental when dealing with different patient circumstances. Patients can present with situations that you have strong personal feelings about. It could be a young patient who is asking about birth control. It could be a patient who is being seen repeatedly for STIs. It could be a patient who is not following the prenatal care plan. In any of those situations, we must always do what is best for the patient and follow office policies and procedures. We cannot give our opinion on how we think the patient should behave. We have a responsibility to inform the provider of any patient issues that are presented.