E34 Prism Schneider on Intimate Partner Violence

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Chad Ball  00:15

Welcome to Cold Steel, the Canadian Journal of Surgery Podcast, with your hosts Ameer Farooq and Chad Ball. The goal of the CJS podcast is threefold. The first is to highlight the best research currently being completed by Canadian surgeons. Second is to offer educational topics for both surgeons and trainees alike. And most importantly, the third goal is to inspire discussion, thoughts, creativity and career development in all Canadian surgeons. We hope you enjoy it.

Ameer Farooq  00:50

Dr. Prism Schneider is an orthopedic trauma surgeon and assistant professor at the University of Calgary. She’s well known for her research on many topics, particularly on the use of thromboelastography in postoperative and hospitalized patients. In this episode, however, we delve into Dr. Schneider’s research on intimate partner violence and how surgeons might do a better job of recognizing it.

Chad Ball  01:12

So Dr. Schneider, thank you very, very much for spending some time with us on Cold Steel today. I really appreciate it, we know how busy you are and it’s absolutely fantastic to have you on. For those of our listeners that maybe don’t know you super well yet, can you tell us where you grew up? What prompted you to go into medicine? Why orthopedics?

Prism Schneider  01:38

Well, thank you first off for the invitation. Very excited to join you guys today. I’m originally a rural Saskatchewan kid. So, I grew up in very small town farming Saskatchewan. And I went off to the big city of Montreal for my undergraduate degree. So I think that’s what eventually led me to the idea of medicine, it was never on my radar. I was very interested in biomechanics and kinesiology and I actually moved back to Calgary to pursue a PhD in Biomechanics and started falling in love with the field of orthopedics. I had the opportunity to work with patients both pre and postoperatively. And I really saw the opportunity for potentially merging both medical and graduate training together, and hopefully actually someday studying my own patients pre and postoperatively. So I guess that really led to the Leaders in Medicine program here at the University of Calgary, where I was able to actually defer my medical school acceptance in order to focus on completion of my PhD. I was very grateful for that opportunity. Went through orthopedic residency here in Calgary, and then went off and did two trauma fellowships; one at the University of Texas in Houston and the other one back at McGill, actually, was nice to go back to my alma mater for that opportunity as well.

Chad Ball  03:05

Despite your love for Montreal and your continued visits there, I’m hoping you’re still a Riders fan.

Prism Schneider  03:14

Through and through, I bleed green, no doubt.

Chad Ball  03:17

I love it. How did you fellowships, just out of curiosity, in Houston, compare or differ from from Montreal? Both in terms of structure and content, maybe, but even more so, healthcare systems in orthopedics and potentially, patients?

Prism Schneider  03:33

That’s an excellent, broad question. I think I was really drawn to pursue my initial fellowship down in a large academic, but very clinically busy center. Which was why Houston was definitely at the top of my list. And it provided exactly that. It was really that whole philosophy of drinking from a firehose. It was incredibly clinically busy, with wonderful learning opportunities that I think actually differ from my day to day opportunities here in Canada. And so, I think having that training opportunity and applying some of the experiences that I had, for example, with the volumes, with a very large volume of penetrating trauma, has really allowed me to develop my practice here in Canada in a way that I think meets the needs of our population.

Chad Ball  04:25

It’s interesting, right? We spend a lot of time talking to our graduating residents and maybe mid-level residents regarding selecting fellowships and there’s of course so many things that go into that, but at the end of the day, if it’s a technical subspecialty you’re looking at, volume trumps not everything, but I’d say almost everything. Is that your experience in orthopedics as well.

Prism Schneider  04:51

Yeah, I think that’s very true. It’s a very technical skill that you actually don’t really learn throughout medical school. When you get into residency, orthopedics is a very niche area, believe it or not. And so, having the ability to learn a whole bunch of different strategies for, perhaps, treating very similar problems, gives you this whole toolkit that I think can be applied in your practice. And I’ve been able to extend some of that to some really great international opportunities, where your resources are different. But having that toolkit in your armamentarium, I think is very helpful in practice.

Ameer Farooq  05:28

Dr. Schneider, one of the things we really wanted to dive deep with you about is all your work on interpersonal violence. That’s such an interesting, and frankly, different kind of topic for, I think, most surgeons to think about, whether in orthopedics or not. Can you tell us how you got interested in that topic?

Prism Schneider  05:49

Yeah, absolutely. It’s a difficult area and I think I liked the challenge of that. But I definitely reflect back to a patient encounter that really sparked the journey of both research and personal and professional improvement with this difficult topic. I was very early in my very first year in practice, and I unfortunately, missed an opportunity, I think, initially to intervene in a patient that was experiencing intimate partner violence. So, she was a young lady, she had an eight month old baby at home, living with her partner. I met her essentially in the preoperative holding area, as she had an ankle fracture requiring surgical treatment. I went through my general information, informed consent, felt that I built fairly nice rapport quite quickly with this young lady. And then, subsequently went on to notice when she went off to sleep for her surgery, that she had bruises all over her body, various stages of healing. And this patient posed a bit of a challenge for me, because I think I had missed my initial window of opportunity to build a bit more rapport with her. So, it subsequently took a number of clinical visits to, number one, provide a safe environment for her to discuss that with me. And to, number two, become that person that she felt comfortable discussing it with. And she has since, this is now several years ago, but she really thanked me at the end of our interactions for not only saving, potentially her life, but potentially that of her young babies as well. So, that experience was very profound for me. And then I kind of dug into the literature in this area and really got aligned with people like Mo Bhandari and Sheila Sprague at McMaster University. And I went on to really learn some of the staggering facts, I think. One of which being that, escalating violence is the number one predictor of intimate partner homicide. And so, I started thinking about these missed opportunities and how we could really find opportunities to close some of these care gaps. So I think that’s where the motivation for this challenging area of clinical work, as well as research, has come from.

Ameer Farooq  08:16

What did you ultimately end up finding in the paper that you published?

Prism Schneider  08:22

So great question, I might even reflect back on a publication that, work going on when I was a senior resident. The PRAISE study was really a pivotal study for, I would say, orthopedics, but hopefully for anybody caring for patients with injuries or fractures. This was a study published in The Lancet in 2013. And again, Mo Bhandari and Sheila Sprague, of out of McMaster University, were the leads on that. And I was a senior resident, we were recruiting patients for this study and I have to say, I think that’s where this all stemmed from. And unfortunately, we did find in a cohort of over 3000 female patients presenting to fracture clinics, across 12 different sites all over the world, that 1 in 6 women who were presenting to our cast clinic had actually experienced some form of intimate partner violence in the prior year. So we also found unfortunately, that 1 in 50 women that were coming to the fracture clinic with an injury were there directly because of an injury due to intimate partner violence. And when you think about 1 in 50, that may not seem that high, but if you think about how many fractures are happening in any given city at any given time, that is a really staggering, elevated number. So I think some of that work actually led to our ongoing work with development of educational resources and the EDUCATE study, again, in collaboration with McMaster University, where we really wanted to identify some of the barriers that healthcare professionals face. We wanted to provide platforms for education and knowledge development. And then we wanted to study that intervention.

Chad Ball  10:09

That’s such a great background story, Prism. It’s such a good example for all of our listeners, from residency all the way forward, about just being attentive and being aware in your environment to some of these issues that are right there. That are, quote unquote, low hanging fruit, that are potentially really big issues. If we pay attention to them, and chase them, and study them, and try and intervene. You guys should be so proud of that. It’s interesting, in looking through a number of your papers on intimate partner violence, not just the CMAJ Open one, but the orthopedic-based ones as well. I don’t want to sound in any way, of course, clueless about it, but it doesn’t overly surprise me for some reason, that surgeons aren’t the best folks, even orthopedic surgeons, at identifying this super high-risk group. You’ve defined the frequency of it and as you said, so has Mo, it’s an epidemic. It’s obviously a huge societal problem. When I think to us, as the general surgical trauma side, both in the US and these uber, uber, uber interpersonally, violent places. I think it tends to percolate up and bubble up a little bit more obviously, maybe than, for the orthopedic surgeon dealing with the fracture. Do you think that’s a fair statement or an unfair statement? I mean it as a little bit sympathetic to the orthopedic world, you know.

Prism Schneider  11:42

I think what’s interesting is actually looking at the definition of what intimate partner violence is. And it really is important to note that it’s not limited to physical abuse or physical injury, which is unfortunately, when we tend to see these patients. And that brings me back to that escalating violence and unfortunately, there’s a lot of, usually pre-existing isolation, psychosocial harm that has come to these patients prior to the actual physical injury, when we meet them. And so again, I kind of always reflect on the opportunity. And one of the other things that we found with the PRAISE study was that only 14% of patients had previously been asked about intimate partner violence when they had a physical injury. And so, I think that’s a huge opportunity, even at the medical school level, to really begin focusing on training opportunities, learning how to be comfortable and confident talking about a really difficult subject area, it actually makes it much easier to integrate into clinical practice.

Chad Ball  12:49

To be truthful, here in Calgary, I have to say that your work has really changed the way that I personally round. When I look at these patients on the trauma service every day, it’s something that’s at the forefront of my mind. And I do ask about it.

Ameer Farooq  13:00

One of the puzzling things that you’re seeing, and what you found in your research, in that throughout medical school, we get lots of lectures about what to look for in terms of child abuse, right? We are shown x-rays, and we’re taught about, what are classic signs child abuse. But I think, much less so about intimate partner violence. Can you talk a little bit about why that might be? And also, how is that different than child abuse?

Prism Schneider  13:34

Yeah, it’s a great question. You’re completely right. I mean, we’re taught the pathognomonic presentation of child abuse. I would say that our pediatric colleagues have done a phenomenal job with really standardizing screening and official screening for child abuse. And it is interesting to see that care gap that has happened when you move into adulthood. I feel very fortunate, we’ve just completed our very first MEDUCATE study, so to speak, where we were approached actually, by the medical students. I give a couple of lectures about MSK injuries, and they use that as a platform to start talking about intimate partner violence. And they actually were the ones who really initiated the need for, and the longing for a bit more education. So, we did an evening event with the medical students; it was a voluntary activity. And we presented a lot of information from EDUCATE, but we also allowed them to do a practical scenario. We had social workers, we had simulated patients, they got some feedback on how they interacted with these patients. And we’re just writing up our results as the feedback that we received from that endeavor. It was very, very positive and very favorable. So again, it’s that opportunity early in training to discuss something that’s difficult to talk about.

Chad Ball  14:57

That’s absolutely so true. Prism, before we leave this topic, I want to ask you where you see this going next. In other words, not only at the micro, but the macro level. What what should we be doing next? Where’s your research program going next? How can we help make this better moving forward?

Prism Schneider  15:18

Thank you for the question. So, maybe I’ll start with micro. Locally, one of the questions that I’m often asked is, there’s always a focus on the female patient. And what about other patients and other types of relationships, for example. And those are excellent questions. I usually will respond with the fact that unfortunately, being a female is the single greatest predictor of being a victim of, or someone who experiences, intimate partner violence. However, the opportunities are huge for actually identifying patients that maybe act in violent ways, to provide some educational opportunities for them, and to really start breaking down that cycle of violence. And so, we are working on locally, a study for validating a screening tool to help identify, but also assist those in violent intimate relationships. And I see that being really, the future. Hopefully, that will be micro to macroscopic intervention, for sure. I think on a national level, for your second part of your question. I think we’re now at the point where our governing bodies like the Canadian Orthopedic Association, the American College of Surgeons, they all have position statements that really emphasize that it is well within the level of responsibility of providing care for injured patients, that it’s our due diligence that we need to be having these conversations with patients. So, I like the direction it’s going at, a more national and international level, with identifying the barriers for why we don’t have these discussions, how we can support physicians in feeling confident and comfortable having the discussion with their patients, and ideally, having all the resources available to them to help protect these patients.

Chad Ball  17:13

Yeah, I think you’re right. When we think about all these brief interventions and patient questioning that becomes so important. Whether it’s smoking cessation in the family doctor’s office, whether it’s what you’re talking about, whether it’s on our trauma service and you’re looking at somebody who’s a drunk driver. As somebody, even [inaudible] brief alcohol intervention. I think we can all do better, and try and capture these patients across a lot of different opportunities in our healthcare system, there’s no doubt. Prism, if we shift gears here for a little bit. Again, for those who don’t maybe know you as well as we do, you’ve been really, really productive academically and clinically out of the gate. When you started to work again, here in Calgary. Whether that’s research, or whether that’s obtaining funding and applying for grants. And then of course, as mentioned, the clinical side of things. How have you done that? And what advice would you have for others starting out in their early staff, them, so to speak, to try and keep that going. We had a great recent conversation with Dave Erbach  about the challenges and the barriers that seem to increase on almost a monthly basis with achieving quality research and funding, and so on. So the hurdles are always there but you’ve done a remarkable and graceful job of stepping around and over them. So how have you done that? And what could you tell us about that?

Prism Schneider  18:41

Thank you for the very kind words, I appreciate it very much. I think one of the things that I did early on, and perhaps advice I wish I would have done maybe even a bit earlier, is to really align with those who truly support you. And they actually support your personal and professional goals. I think that, we talk about mentorship very frequently. And it’s a word that maybe gets thrown around or perhaps even misused quite commonly. I think a really nice definition that I’ve heard about mentorship is, a mentor is someone who wants to see you exceed their goals for you and to really support your own goals. So, I think aligning with people that are truly willing to support your initiatives and move your group’s agenda forward has been what’s been really helpful, and that can be difficult early on to, sort of, align yourself and identify who those people may be. But having varied mentors, whether it’s clinical research, work life balance, I think that’s really where I feel very supported by a great team.

Chad Ball  19:53

It’s true, your trauma orthopedic group here in Calgary is fantastic. You have such a great collaborative group, for sure. I think it’s also interesting to reflect upon your initial comment about the fellowships you did. Because I would say that, for me personally, a lot of my, honestly, academic support and mentorship doesn’t necessarily come from the place I work in now, it doesn’t come from Calgary. It comes from those experiences all through the world, really. So we can always carry those mentors with us and tap into them and I think it’s very powerful. I’m sure you’re tired of talking about COVID, I have no doubt all the listeners are tired of hearing about COVID. We certainly talked about it intermittently, in a lot of different ways on this podcast, but maybe just to finish up. What are the impacts you think of COVID with regard to an intimate partner violence? In general, what are your comments? I’ll preface it by saying, we were lucky enough to write a couple of papers based on looking at trauma volumes and mechanisms and variability in those things, both in the US and Canada with regard to a number of economic indicators. Whether it’s gasoline prices, or GDP, or whatever. And clearly, you see interpersonal violence spike, everywhere, and in some places, incredibly so, when the economy struggles. How does that relate to your work about partner violence?

Prism Schneider  21:28

It’s an excellent question. It was very interesting, at the very end of March, the United Nations actually issued a statement of warning, and it was pretty profound. That the worldwide impact of intimate partner violence was inevitably going to increase due to the COVID-19 pandemic. And unfortunately, that’s exactly what we’re seeing. So, China reported very early on a huge rise in the incidence and the severity of intimate partner violence, in their experience. And then locally, Vancouver, very early on, in April, reported 300% increase in their calls, once the isolation restrictions were put on. I think if you really think about the scenario, the measures that are of utmost importance to minimize the spread of COVID-19, unfortunately, reinforce an environment that actually facilitates isolation, and can really provoke violent behavior. I’ve been fortunate to have a wonderful group of local social workers and employees in the domestic violence sector of our city. And here in Calgary as well, we’re seeing 30% to 50% increase calls to our domestic violence and sexual violence crisis lines. The number one complaint at the moment to a general crisis line is actually family conflict or family issues. So I think, unfortunately, this pandemic has huge ripple effects, certainly economic, but I think within each person’s home as well. So, I think, if I could, the opportunity is very much there, again, to really try to educate ourselves on how we can identify patients that might be at higher risk. Really try to keep that hyper vigilance when we’re dealing with patients, particularly with injuries that are presenting as we’re, kind of, rushing to move patients in and out of the hospital as quickly as possible, we certainly don’t want to overlook these patients. The EDUCATE program, there are a number of other programs. Real Talk is another good example where you can actually do online training to just build a little bit of confidence and comfort in discussing this difficult issue with patients.

Chad Ball  23:50

So well said. Prism, let’s just end, for a slow guy like me, with your advice on, whether it’s for a general surgeon, or a surgical resident, or an orthopedic surgeon, it doesn’t matter. What should you do mechanically if you suspect and potentially identify intimate partner violence? So I’m rounding, I’ve had the discussion, I think this is a clear case of it. What do I do next?

Prism Schneider  24:20

Yeah, it’s a great question. I think the number one fear and the number one barrier that we hear from people is what to do if you get a disclosure. And so, I think that learning your local environment is the first step. So, who is your social worker? Who’s a point person that can help you? Because the goal of asking patients is not necessarily to have all of the right answers of how to provide immediate assistance, but it’s to know where to go locally so that you can build a support team around that patient. And so, I would suggest that the best way forward for us universally, is to be asking all patients regardless of any predisposition that you may have any pre-suspicions or pre-judgments. Because, by normalizing the language, just like we ask about other medical issues, will really help to bring this issue to the forefront, make us all much more comfortable in discussing with our patients, and then learning about local resources to provide the support that those patients may need.

Ameer Farooq  25:33

You’ve been listening to Cold Steel, the official podcast of the Canadian Journal of Surgery. If you’ve liked what you’ve been listening to, please leave us a review on iTunes. We’d love to hear your comments and feedback. So feel free to email us at podcast.cjs@gmail.com or connect with us on Twitter @CanJSurg. Thanks again.