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Groundbreaking programs at San Francisco General Hospital may well change the way the entire U.S. health care system deals with domestic violence. To understand why, you have to understand Dr. Beth Kaplan.

Wednesday, Apr 18 2001
It's a couple of minutes past 7 on an overcast March morning, and Zone 1 of the S.F. General emergency room is jammed. Rounds are ready to start.

The staffs from the overnight and morning shifts are crammed into a 15-square-foot area loosely bounded by a large white marker-board, the zone's administrative desk, and a few semiconscious bodies laid out on gurneys against the corridor's walls. The room is loud, an almost startlingly unclinical mix of socializing and situational briefings. It sounds a lot like a teacherless high school classroom, right before the bell rings.

As she frequently seems to be, Beth Kaplan is running a few minutes behind. But since she's the attending physician for the morning shift, nothing can really start without her. She sneaks up on this scene with something of an odd gait, probably owing to her chronically bad back. With red scrub pants shuffling, almost gliding, gingerly beneath a white lab coat, she happens upon one of the overnight nurse practitioners, Tamara Ooms, who, probably sensing the time constraints, skips the formalities.

"DV night," Ooms sighs, in a tone that suggests here we go again. Kaplan -- who also runs the hospital's domestic violence program, serves as medical director of both the hospital's rape treatment center and its soon-to-be-opened victim recovery center, and teaches two classes at UCSF medical school -- has been slouching, but immediately snaps to attention.

"We've got a shoulder, a stabbing, a pinch, and a woman who got beaten up in a shelter," Ooms explains.

Even though the (separated) shoulder will culminate in a police report, the case that appears to intrigue Kaplan involves the woman from the shelter, who was struck on the head with a glass bottle. As a random act of violence among strangers, the incident would seem to be as far from domestic abuse as violence gets. At any other area hospital, that assumption would likely stand unchallenged.

But here, where every woman who enters the emergency room gets screened for abuse, Ooms found a long history of domestic violence. That history ended only when the woman's boyfriend went to jail last year, on charges unrelated to abuse. Not only had she never received useful counseling or psychiatric help for her repeated traumas, but her boyfriend is scheduled to be released from jail at month's end. She's relatively certain he'll be coming after her as soon as he's able. She's afraid for her life. But because she came to S.F. General, she'll get help.

Most victims of domestic violence who come to emergency rooms do so with injuries that are minor -- a bad bruise from "falling," or headaches that are remarkably chronic -- and most leave with their pains and injuries treated, and the violence they've endured still a secret. During the past six years, however, S.F. General -- or "The General," in medical patois -- has become one of the nation's most aggressive hospitals at identifying, treating, and intervening in domestic violence cases. The hospital already uses one of the nation's most effective screening protocols, and is in the process of upgrading it by adding a team of nurses who are trained in forensics and will gather evidence in the emergency room as they help treat and soothe victims. It also intervenes when screening for domestic violence, confronting victims and directing them to a variety of resources, including legal help, that can make their lives easier. S.F. General is absolutely the first hospital to actively assess whether such intervention works. And by the end of summer, the hospital will open a center, located off-site, geared toward helping victims of all violent crimes recover from their traumas.

It's an innovative medical culture that, experts say, might end up changing the way the American health care system treats domestic violence. And if you ask the people involved how it happened here, most of them point to Beth Kaplan, who somehow managed to convince an organization that is at once chaotically busy, endlessly bureaucratic, and chronically underresourced to undergo a significant institutional change, and to begin dealing innovatively with a social problem most hospitals don't even consider a health care issue.

All teens have their hangouts. Some like shopping malls or diners, others prefer parks and playgrounds. Growing up in a slowly decaying section of Baltimore (which her family eventually abandoned for the suburbs), Beth Kaplan, now 38, had her own preferred high school hangout: the R. Adams Cowley Shock Trauma Center at the University of Maryland Medical Center.

"Sometimes I'd just go to hang out," Kaplan recalls in the S.F. General emergency room, as a patient's anguished bellowing bounces ceaselessly through the department behind her. "I don't know what it is about ERs, but something about them always attracted me."

If Kaplan's leanings toward medicine were apparent early (after leaving high school, she went premed at the University of Maryland's College Park campus), her passions for it didn't crystallize until a few years later. At the time, she was in her second year at the Vanderbilt University School of Medicine, but her interest in women's health issues -- and particularly domestic violence -- wasn't born in class work, but in the problems of some classmates.

Had Kaplan paid a little more attention during anatomy class, she might have noticed that the couple she partnered with bickered. She might even have noticed the male half of that couple trying to stab the hand of the female half with a scalpel, while they worked inside a cadaver. But Kaplan didn't notice until a few weeks later, when her female anatomy partner telephoned, in tears, and wanted her to come over.

"Her face had been beaten," Kaplan says. "She had a fracture, and it really shocked me, because they were very upper class, very proper. They didn't live like students at all. ... And, you know, it gets you thinking: If it can happen to someone like this, it could happen to anyone."

But what affected her as much as anything that night, she says, happened an hour or so later, in the emergency room. "I was sure the doctor would just treat her injuries and send her on her way, but he didn't," Kaplan says, remembering how the doctor talked to her friend about her relationship, explained to her that other people were going through the same thing, and even helped lay out legal options. He also urged her to change the locks on her doors.

"It was ...," as Kaplan recalls, "amazing."

Kaplan spent two years at Boston City Hospital; they nourished both her passion for women's health issues and her reputation in the field. They also wore her down, because she spent her time in Boston chaotically balancing two full-time jobs: acting as the emergency room's chief resident (that is, its supervising physician); and conducting what turned out to be significant research on ectopic pregnancy, which occurs when an embryo begins growing in one of a woman's fallopian tubes, rather than in her uterus. Kaplan established a correlation between the often fatal condition and the prenatal symptoms of abdominal pain and bleeding. Her research almost certainly saved lives, and almost seemed to imperil her own.

"Beth is probably the only person I've ever known who did groundbreaking research while being chief resident," recalls Yale University emergency medicine professor Gail D'onofrio, who supervised Kaplan in Boston. "It almost killed her in the process, though. She was down all the time, pulling her hair out, talking about how she couldn't do it. But she did it."

Kaplan survived Boston, and in 1993 she accepted an offer to become an attending physician in the emergency room at S.F. General. "The General" was -- and is -- ground zero for the medical fallout from urban blight in San Francisco. Its status as the city's largest public hospital means it serves a population that is primarily uninsured and poor, and therefore prone to drug use, violence, and other social ills. As the city's primary trauma center, S.F. General receives more violence victims than any other local hospital. And its Inner Mission location, in close proximity to gang activity and public housing, brings the hospital windfalls of local trauma traffic as well. For Kaplan, who had been interested in urban medicine since her days at Baltimore's trauma center, The General felt like home.

Like any major trauma center, it was flooded with domestic violence victims. While most of them would pass through treatment undetected, enough cases were apparent that emergency room workers began to take notice. "Back then, we really weren't doing anything about it," Kaplan recalls. "We were writing names in a book and not following up at all. There was lots of concern about the issue, but no real sense of what we could do about it."

Kaplan's arrival at S.F. General roughly coincided with the launching of a pilot program by the San Francisco-based Domestic Violence Prevention Fund. The Fund, a prominent national nonprofit organization based in Potrero Hill, only a quick walk from S.F. General, was seeking 12 hospitals -- half in California, half in Pennsylvania -- that would agree to teach most of their emergency room staffs -- from doctors to janitors -- how to identify domestic violence victims, and then how to direct those victims to shelters and other aid. Kaplan and a few other hospital staffers got word of the search and began to lobby.

"There was definitely begging and pleading involved," she says.

In the end, the lobbying succeeded. The proximity of S.F. General to the Fund's office and the high-risk population serviced by the hospital's emergency room made it an ideal candidate. By the end of 1994, training was under way. Kaplan was in charge, and the timing was ideal. The media spectacle of O.J. Simpson's murder trial was in full swing, and his history of violence against his wife, Nicole Brown-Simpson, was inescapable. The entire country had heard the anguished 911 calls and seen the pictures of her after she'd been beaten. And even though the jury found Simpson innocent, the entire country saw how it ended for Nicole.

"I think people were able to personalize the issue for the first time," Kaplan says. "Suddenly, it's a real problem, not just an idea. ... Also, it showed everybody that the ultimate outcome of domestic violence is often lethal. And, from a medical perspective, we're always trying to prevent lethal outcomes. So it made [promoting awareness] a little easier."

Still, the transition was far from smooth. Nurse Lettie Muller, 51, who has been in the S.F. General emergency room for nine years, remembers Kaplan absorbing her share of sarcasm and rolled eyes while she urged doctors, nurses, and paramedics to make a habit of screening for violence. "She was asking a very busy place to do a lot of extra stuff," Muller recalls. "So a lot of people questioned why."

Kaplan knew she was being sanctimonious; she chose not to care. "People got so sick of me on my bandstand," she says. "During rounds, I'd always be trying to remind people about screening [for violence]. I knew I was being annoying. That wasn't my concern."

By 1998, screening for histories of partner violence at S.F. General was increasingly routine -- and effective. Whenever possible, hospital staff were trying to screen every woman they saw older than 13, whether she was in for a broken arm or an asthma attack. And staffers were catching two or three people a day with "active" histories of violence that they wouldn't have noticed otherwise. For that, there were accolades: S.F. General's program received an award from the National Association of Public Hospitals for "improving the health care response to domestic violence."

A research effort led by Kaplan and funded by George Soros' Open Society Fund showed that 13 to 14 percent of all women and gay men being treated at The General were either currently experiencing domestic violence or had experienced it within the past year. As part of that research, once abuse was documented, nurses "intervened" with patients; that is, they explained to the patients that they were victims of illegal activity, that domestic violence is a widespread phenomenon, and that resources were available for domestic violence victims.

It sounds simple, but -- outside of the hospitals in the Family Violence Prevention Fund's pilot program -- this type of intervention was almost unheard of in hospital settings.

It may not be a stretch to say there has been more research about the lack of domestic violence programs in health care than there has been about the programs themselves. One of the most significant of those studies was conducted at S.F. General by Michael Rodriguez, a family physician and researcher there. In 1999 he found that only about 10 percent of primary care doctors bother to ask patients who are not already injured about violence in their lives. At most emergency rooms, the number is almost certainly lower.

S.F. General is only one of a tiny handful of hospitals to screen for and intervene in domestic violence cases; it is the first to try to assess the effectiveness of medical intervention in domestic violence cases. Researchers -- led, again, by Kaplan -- interviewed 120 people about changes in their quality of life after they were confronted about their abuse during hospital interventions. Almost 90 percent of them returned for a follow-up interview four to six months later, an astonishing statistic considering the high-stress environments most of the patients were coming from.

Other domestic violence experts say the return rate alone is nearly proof the intervention succeeded. That trust in the health care setting isn't lost on Kaplan.

"For a lot of these women, [the intervention] is the first time they realize that what's happening to them is an issue," Kaplan says. "And because they feel safe in a hospital, and because they trust their doctors and nurses, they're willing to talk about things they might not anywhere else."

Deirdre Anglin, a renowned domestic violence researcher at the University of Southern California, says that Kaplan's follow-up work on health care intervention in domestic violence is unprecedented and could change the way victims of partner violence are treated throughout the health care system.

"We've been pushing very hard to get health care providers to do DV survivors," Anglin says. "But, if you're going to intervene -- these are expensive programs -- what you need to know is: Does it work? If it does, then we'll replicate it all over the country."

The higher-ups at S.F. General have been moved enough by the anecdotal evidence from the intervention study (a formal analysis won't be finished until sometime this summer) to act on the results. The hospital's psychiatry department has already received $1.4 million in state budget grants for an off-site recovery center tailored to the needs of victims of violent crime.

Because about half of the people injured during violent crimes develop psychological or social difficulties in the months and years that follow, the center is intended to provide what psychiatry department head Robert Okin calls "treatment and wraparound services," which link victims not only with medical staff, but also with relevant city services. The center will also let victims avoid the stigma attached to battered-women's shelters. It is not unusual, in San Francisco and around the country, to find hospital-affiliated centers dedicated to rape and sexual assault victims. The new center planned by S.F. General apparently will be the first to also screen for and serve domestic violence patients.

Her Saturday shift is over, and Beth Kaplan is soaking up what's left of the early spring sunlight over an Israeli beer outside the metal-hued Universal Cafe, a few blocks from the hospital. She's wearing a black leather jacket with a red alligator purse slung over her shoulder, a body-hugging white waffle-knit shirt tucked into her scrub pants.

Beneath a boxy pair of gold-rimmed shades, she's laughing about how, just 24 hours earlier, she was almost paralyzed in bed thanks to her occasionally crippled back. The pain kicked in, this time, after 12 hours in the ER on Wednesday (7 a.m. to 11 a.m., followed by 11 p.m. to 7 a.m., with a full slate of meetings in between), followed by an appointment-filled Thursday. To cope with the pain, she uses a Middle Eastern therapy called Feldenchrist, which essentially involves the relearning of the body's most basic movements. The way she holds her head talking on the telephone or leans over a patient, for instance, can have an effect that is subtly crippling.

This, of course, isn't the first time she's worn herself down. Her days in Boston, juggling the emergency work with the groundbreaking ectopic pregnancy research, took their toll as well. But she's quick to point out that "it was good work," valuable fodder, as it turned out, for a bunch of medical niche publications, including emergency room pamphlets. Which was nice. But this domestic violence project might just land her in the über- prestigious Journal of the American Medical Association.

And that thought gets her grinning.

"The ectopic pregnancy stuff was, umm, kind of, uh ..."


"Yeah," she laughs. "This work should appeal to a more general audience."

But that audience will have to wait a bit longer: Even though the data from her follow-up interviews is all gathered, she says it'll take her a month or two longer to write up the findings. And, having finished the reporting, Kaplan suggests the piece will, in the end, include as much human interest as hard science. "We meant for this to be a scientific study, but we kind of got involved," she says.

No one in San Francisco General Hospital's emergency room -- at least, no one who worked on Tony Zachary's wife -- will ever forget what he did to her that March night in 1999. After stripping off her clothes, shoving a sock in her mouth, and tying her to her bed with electrical chords, he repeatedly burned her with a curling iron. "He took his time," a police investigator told a San Francisco Chronicle reporter at the time, noting that the victim would be scarred for life. "This is an evil, evil act."

Pictures of the victim -- which Kaplan kept -- say as much. More, actually. They show a nude, mutilated body, nearly tiled with more than 30 separate, severe burns. A close-up of one burn, on the stomach, shows an off-purple welt the size and shape of the iron itself. Others show similar marks on her chest and arms. And legs. Then there are the panned-out shots, where you see each individual burn in relation to the others, and you wonder how these two people stayed married for six years. The photos are almost impossible to look at without cringing. Although, having looked at them for two years, Beth Kaplan can.

Today, Kaplan is sitting in her car, which is parked in S.F. General's 23rd Street garage; she's ready to head home. There are pale rings around her eyes, rings pronounced enough to be visible even through the dirty-blond hair that lightens as it falls in front of her face, while she looks down at the photos.

The shift she's just completed was intense, but relatively typical, complete with a standard flow of half-conscious junkies; the homeless "regular" the whole staff thought was dead who showed up for treatment; and the woman who had been run down from behind, on the sidewalk, by a sport-utility vehicle, leaving her with a broken back and leg, a crushed pelvis, and tire marks across her abdomen. She is, very likely, paralyzed for life. (Kaplan, of course, had the privilege of sharing this diagnosis with the victim's husband and child.)

Kaplan's is a hard job, and not one that lends spare time and energy for research on the side. I ask her why she continues to pursue domestic violence as a medical issue; she gestures toward the Polaroids of the former Mrs. Zachary.

"I keep these," she says, pulling the car out onto Potrero Avenue, "so I remember."

About The Author

Jeremy Mullman


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