Speaking With Care

Dr. Julianne Toohey was conducting a usually painless ultrasound examination of a pregnant woman a few months ago when she noticed her patient wince.

After some gentle questioning by Toohey, the woman wept and said her husband had straddled her abdomen and tried to strangle her.

Because the husband was waiting outside the examining room, Toohey said her patient had just minutes to decide whether she wanted the doctor to call the police and change her life forever.

“I told her, ‘We can call the police and get you some help. This is your only opportunity.’ I was shaking,” Toohey recalled.

The patient’s husband was arrested in the waiting room.

Until recently, many doctors have looked the other way when they’ve seen signs of domestic violence. They considered it none of their business.

But Toohey, 40, an obstetrician and gynecologist at UCI Medical Center in Orange, has made spousal abuse her cause. She is encouraging other doctors to do the same by speaking several times a month at Orange County hospitals, medical offices and at medical conferences.

Toohey tells physicians and nurses how to screen patients for domestic violence because “docs are very uneducated in the field of domestic violence, and they don’t know that they are,” she said.

Recently, she also spoke to 200 police investigators attending a seminar on domestic violence in Irvine. And she was invited by the Orange County district attorney’s office to teach police investigators how to work with doctors on domestic violence cases.

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Spousal abuse occurs on both sides of the gender line. Because of her specialty in treating women, Toohey sees what happens to women, often pregnant ones.

For the investigators, Toohey spared no ugly detail of blackened eyes and bruised arms. She described the “blunt force patterns” made by belts, fists and bites. “A baseball bat usually leaves two parallel lines,” she told them matter-of-factly.

On a large screen, she showed a picture of a woman whose arm bore a massive bruise. “You’ll find the same kind of bruise on the other arm because he grabbed her,” she said.

Another picture showed a woman’s head covered in lacerations. “I tell doctors to go through the scalp very carefully. You can miss huge bumps. It’s a great place to hide injuries.”

Toohey described burns from flat irons, curling irons, ropes and other everyday objects used as weapons. “The kitchen is a very dangerous place,” she said. “One of the worst injuries I’ve seen was splattering of hot oil on a woman’s face.”

To police officers, such horrors are nothing new, but many physicians aren’t accustomed to that “level of ugliness,” Toohey said.

She began her campaign about five years ago after learning that although domestic violence was a widespread problem affecting many patients’ health, many doctors knew little about it.

“Domestic violence is the No. 1 cause of injuries to women in the reproductive age group,” she said. “As doctors, we study all of these obscure diseases when domestic violence is what we should be worried about. For doctors not to take it on is wrong.”

Many physicians would have nothing to do with domestic violence until a couple of years ago, when new state laws required them to report injuries they suspected were caused by domestic violence.

“Mandatory reporting has helped me in many ways, because now docs are asking me to talk about domestic violence all the time,” Toohey said. “Before, they didn’t think it was their role. Their attitude was ‘Just call the social worker.’ But [reporting] puts domestic violence in the proper arena. It’s a crime we can prosecute.”

Some doctors, however, continue to argue that reporting is a violation of their patients’ trust and could put patients in greater danger of physical harm, she said.

“They need to be reassured that appropriate steps will be taken [to protect the patient]. We have such improved police intervention that I really feel reporting is worthwhile,” she added. “Once a patient is in [an emergency room], you’re kind of kidding yourself if you think she’s not already in serious danger.”

Toohey encourages doctors to notice subtle clues that a patient is being abused, because victims might be too frightened to speak up.

“Often they’re ashamed and humiliated to be in [an abusive] situation,” she said. “They will deny it, even to the point where they’ll say they bit themselves, which is what we saw in our last case.”

Among the more subtle signs of abuse:

* Patients will have a variety of vague complaints, such as chronic fatigue, indigestion or sleep and eating disorders, and they’ll frequently change their stories about what ails them.

* Sexually transmitted diseases are common because their abusive partner often forbids the use of condoms--or any birth control, for that matter.

* Many patients have injuries in various stages of healing. “I’m not looking for severe injuries; I’m looking for mild, subtle injuries that precede more serious ones,” Toohey said.

* Throughout the patient’s visit with the doctor, the partner hovers nearby, not wanting to leave the patient alone with the physician.

Doctors are only obligated to report treatment of an injury caused by domestic violence. But though they need not call police merely because patients admit they are being abused at home, they can refer patients to counseling or a shelter.

Because abuse is so common, physicians should ask all patients whether they are being abused at home “before they end up victims,” Toohey said. “I routinely screen all of my patients, and I’m amazed at how many times I pick up a history of abuse.”

Some physicians believe they don’t have time to routinely screen everyone, and Toohey admits it’s a challenge. “They have maybe 10 minutes with a patient” because of pressures from their HMOs, she said.

She suggests a simple screening, asking patients a few appropriate questions just as they would ask patients whether they smoke or exercise.

“They can just say, ‘Violence is common in family life. Has anyone ever hurt you?’ Sometimes you’re just planting a seed. I’ve had patients answer, ‘No, no, no,’ then four months later they’ll confess.”

Most important, doctors should ask injured patients how it occurred. “How many times has a woman been in an emergency room with injuries, and no one asks if she’s been battered?” Toohey said.

Toohey also suggests physicians place pamphlets about domestic violence throughout their office and post abuse hotline numbers.

“Julianne’s one of the few physicians in the community who understands the issue of domestic violence,” said Vivian Clecak, founder and executive director of Human Options in Irvine, where Toohey is a board member. The program assists victims of abuse by providing emergency shelter, counseling and other services. “We need more doctors like her.”

Toohey works as a specialist in high-risk obstetrics with Perinatal Associates of Southern California based at UCI Medical Center. She’s also an assistant clinical professor with the UCI School of Medicine, where she gives seminars about domestic violence to students.

Teaching Students What She Has Learned

“Not once [as a medical student] was I given any lecture on domestic violence,” she said. “Hopefully, by the time these students graduate they’ll have a much better understanding of it.”

Toohey serves on the Orange County Family Violence Council and the board of the American Cancer Society of Orange County, helping with community education for Latinos. Every Wednesday she co-hosts “Comunidad,” an educational cable TV program in Spanish that airs on Century Cable in Anaheim. Toohey’s mother emigrated from Mexico City, and Spanish is her first language.

Such volunteering is considered a part of any UC professor’s job responsibilities. Toohey said she believes everyone should be involved in their community.

“It’s not enough to go to school, get a job and a nice car,” she said. “You have to give back.”

Through Human Options, she also speaks to teens about early warning signs of date abuse.

“Dating is the most important thing they can do in high school. We don’t talk to kids about healthy, appropriate relationships,” she said.

Toohey understands it well. She met her husband, Kevin, when they were sophomores in high school. Born in Fullerton, she attended Cornelia Connelly High, an all-girls Catholic school in Anaheim, and her husband attended Servite, the nearby Catholic high school for boys. They married when she was 18 and she had her first child at 19.

With three small children to care for, she still was able to earn a degree in biology from UCI and graduate from the UCI School of Medicine. She finished her residency there in 1992 and her fellowship in 1994 in her mid-30s.

“I did it slowly but surely. The kids remember me studying a lot,” she said. “We always had lots of help. I have a great family and great support.”

She and Kevin, president of an insurance brokerage, live in Lake Forest; their 21-year-old son, Damian, is studying to be an aerospace engineer at UCLA, their 19-year-old daughter, Mikey, attends Loyola Marymount University in Los Angeles, and 17-year-old Megan is a senior at El Toro High School.

“Every day, I decide what’s the most important thing I have to do today. Sometimes it’s spending time with my 17-year-old,” she said.

She’d like to see more physicians speak out about domestic violence and date abuse.

“I think we feel we’re already doing so much in our jobs, [but] I’m encouraging them to do more,” she said.

For information about Human Options’ speaker program, call the office at (949) 737-5242, Ext. 14. The agency’s abuse hotline is (949) 854-3554.