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Evaluating IPV in the Fracture Clinic

IPV Clinic staff

from left to right - Mo Bhandari, Lesley Gotlib Conn, Aynsley Young, Emil Schemitsch

15 years ago, Emil Schemitsch saw a young business woman in the fracture clinic who had been recently treated for an open tibial fracture. She stated that she had been at a party wearing high heels, then fell over, and fractured her leg. Several years later, a lawyer told him that her leg had actually been hit with a baseball bat by her boyfriend. He had wondered how a fall from high heels could result in an open tibial fracture - it seemed highly improbable, but he had not pursued the true cause at the time in a very busy clinic.

Mohit Bhandari of McMaster University (see article Fall 2010) has been working with Emil on the Intimate Partner Violence (IPV) problem for the past several years. When Mo was a resident at McMaster, he and his wife, who is a social worker, started thinking about this issue. Mo and Emil subsequently connected and published a survey, which found that 87% of Canadian Orthopaedic surgeons believed IPV victims represented fewer than 1% of patients in their clinics. They subsequently published a study in the Journal of Bone & Joint Surgery of 300 women who were interviewed about the incidence of IPV and found that the opposite was true. “There was a 1 in 3 chance of IPV in the past year, especially using the broader definition that includes emotional, sexual, and physical abuse. 9% had been exposed to physical abuse and 2.5% were in the clinic that day for a fracture or dislocation that was directly the result of physical abuse. “The problem is quite a bit bigger than we had assumed. Orthopaedic surgeons are in a good position to look for and recognize this problem. When women present with traumatic injuries, they are often worried primarily about the injury and it is often only in the follow-up visits that the orthopaedic surgeon has the opportunity to ask about and respond to an abuse disclosure.” Mo and Emil have completed an international ten clinic study of 3,000 women that has been published in the Lancet. The prevalence was similar in this much larger number of patients.

Nurse Aynsley Young has done independent work on IPV in the Emergency Department at St. Michael’s Hospital, where she is promoting universal screening for IPV. Emil and Aynsley have developed a screening program in the MSK clinics. There is a tool kit with binders of articles and protocols, a list of questions to ask, and a list of resources for support in the clinic. When he learned about this project, Ori Rotstein said: “This is a great opportunity for knowledge-translation” and connected Leslie Gotlib Conn, a Knowledge Translation Research Manager at St. Michael’s Hospital to join Emil and Aynsley. Through focus groups with residents, the group developed questions to ask, identified barriers, and completed a workshop with new PGY1 orthopaedic residents, supported by a grant from the Dean’s Fund for Education.

The group is modeling their approach on Earl Bogoch’s osteoporosis studies at St Michael’s. “Earl and his colleagues now have an osteoporosis coordinator who makes sure that patients with fractures are on the correct medications for osteoporosis and that they stay on them. The government gave Earl a grant to set up osteoporosis coordinators in fracture clinics across Ontario. The same model is needed for the IPV project. IPV assessment is difficult in the fracture clinic setting: 80- 100 patients in 5 hours in a clinic filled with cast technicians, nurses, and a thin curtain between patient gurnies offers no privacy for the kind of questions that might uncover or illuminate IPV in follow-up visits. It should be possible for the surgeon to ask some simple screening questions and then to say: ‘I’d like you to talk to our social worker’. The patient could then go to a private area and be seen by an IPV coordinator who could spend sufficient time to evaluate the causes and approach to the abuse. In the future, it will be important to do a longitudinal evaluation to see what happens over time to the abused patients and what coordinators and interventions can do. This is a project for the future.”

As past president of the Canadian Orthopaedic Association, Emil is coordinating with the CEO and staff of the association on publicizing and teaching about this problem. The issue has also been described on CBC radio and morning television.


  1. The notion that ‘it is not a common problem, or that it isn’t a problem that I should deal with’.
  2. The clinic environment lacks privacy, is time constrained and allows no confidential conversation. In the absence of support, surgeons tend to think ‘I should skip that part of the history, since there is nothing I can do about it’. Moral distress affects caregivers “when they know the right thing to do, but institutional or other constraints make it difficult to pursue the desired course of action”
  3. Lack of resources- whereas the osteoporosis coordinator is there ready to pick up the thread of neglected medication, there is no coordinator for spousal or inter-partner violence or abuse.

“The old model of a clinic with all 7 wrist fractures in the same room near the cast cart means there is no time for anything but moving on to the next fracture. The outcome is that the patient will return with another fracture in the case of osteoporosis, or may be murdered in the case of IPV. It is appropriate to ask the question: ‘Are you safe?’, but doctors cannot ignore the wishes of patients to avoid the police. ‘If they are called, he’ll kill me, or my kids will be taken’. We need the help and intervention of social workers to help make this problem manageable. There is a social worker connected to the entire MSK program, but there is no dedicated IPV coordinator, like the osteoporosis coordinator. The model is there. ‘We need to apply it in IPV. The challenge is to make IPV screening and referral standard operating procedure.’”

A very active clinician and surgical investigator, Emil recently completed his term as Head of Orthopaedic Surgery at St. Michael’s Hospital. He has over 300 publications, and has held many grants. He has four childrenone playing in the Ontario Hockey League, and one who will soon enter it.


Leslie Gotlib is a knowledge translation specialist in the Department of Surgery at St. Michael’s Hospital, a position created by Ori Rotstein. Her background is in anthropology. She is principally involved in collaborative initiatives, such as the abuse screening project, which requires her to put studies together, train surgeons and residents and respond to questions and problems that arise in these initiatives. In response to the interpartner violence issue, Leslie developed an educational workshop for the orthopaedic residents. This will soon be extended to all entering first year surgery residents. When Aynsley Young served as the research coordinator for surgery, she championed abuse screening in the emergency room. There was some pushback in the emergency room - screening as part of the routine history seemed to some patients and caregivers to be too invasive in the personal affairs of patients. It was up to the surgeon to decide when questions like “Are you safe at home?” might be appropriate. Leaving this issue in the hands of surgeons resulted in spotty coverage, so Leslie brought it into the resident training program. She carried out focus groups with R1,2 R4 residents. “One of the important lessons from these conversations was that residents need to learn about this topic from orthopaedic surgeons, not from anthropologists.”

“We developed a description of the knowledge gap. We invited Mo Bhandari, who gave a compelling presentation. Mo said: ‘You will never do anything more meaningful or important than saving a life by asking this question’. Emil Schemitsch gave the profession’s response, describing the actions of the Canadian Orthopaedic Association and others to the challenge. Lesley gave feedback from the focus groups, describing the barriers to success, such as time and space constraints, and the surgeons’ concept of their role. In general, surgeons said ‘we don’t explore the stories of injuries. We take a very modular view’. Aynsley Young described how to ask, and gave a very effective presentation about indicator based screening. She emphasized that we should not start from bias, looking only at the disadvantaged for evidence of interpartner violence. The workshop also included standardized patients – one male and one female- who were asked about interpartner violence. Fourteen orthopaedic residents attended the workshop at the Mount Sinai Hospital classroom. The session was 2 hours long and there were no ‘blackberry moments’. The attention was excellent. Evaluations based on questions like: ‘I know; I am comfortable asking; or I’d be prepared to act’. All went up, especially the ‘prepared to act’ segment. There was with a dramatic improvement from awareness to preparedness. The Journal of Bone and Joint Surgery will be asked to publish a qualitative study on the subject.

Other initiatives for translation that are being developed are enhanced recovery guidelines, an important project funded by the Canadian Association of Healthcare Organizations. Robin McLeod is the lead on this program, which will be conducted in 15 hospitals. There is an intervention package that includes preoperative education and preparation, and perioperative steps, including anesthesia, the use of epidurals, patient controlled analgesia, intravenous therapy etc. The postoperative segment includes early mobilization, early resumption of regular diet, and pain management. St. Michael’s Hospital does something like John Semple’s home monitoring, training caregivers to inspect the wound for infection and fill out a yes/no form. Leslie says: “It’s is very simple. My 3 year old can do it.” She is implementing guidelines and developing an educational program to move the program on enhanced recovery forward.

Leslie studied medical anthropology with a collaborative program in gender studies at the University of Toronto. She is enjoying working “in the unique culture of surgery”.

She is the mother of two girls, ages 6 and 3. She runs, reads, and recommends Sheryl Sandberg’s “Lean in” as a good leadership book for anyone.


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