Sitting in an exam room, Dr. Elliott Schulman reviews the chart of a 20-year-old patient who has been in his care for years. A neurologist at Lankenau Medical Center, Schulman had tried everything to manage her painful refractory migraines. “RMs have frustrated us for decades because our treatment modalities have proven ineffective,” says Schulman. “We haven’t been able to prevent them from happening or stop them when they do happen.”
If anyone can determine the source of RMs, it should be Schulman, a nationally recognized headache authority. He literally wrote the book on the subject, co-authoring the American Headache Society’s definition. Still, RMs present a medical conundrum for even the most seasoned expert. If medicine wasn’t the answer, were neurologists asking the wrong questions?
At a headache conference, one of Schulman’s colleagues posed a different theory: “Why do you think people who are abused have more refractory migraines?”
“I’d never thought of it like that,” Schulman admits. “Could there be a link? Could abuse cause biochemical changes that result in migraines? And if so, could we then devise new treatments for our patients?”
Then came the day when Schulman’s patient returned to his exam room, again suffering from a refractory migraine. Having exhausted every treatment option, he posed a question that changed her life—and his.
“I said, ‘In all of the years I’ve been treating you, there is one thing that we’ve never discussed. Have you ever been abused?’ Right away, she said, ‘Yes. I was raped when I was 12.’ I said, ‘Why didn’t you tell me?’ She said, ‘You never asked.’
“I was stunned and saddened by both answers,” says Schulman. “There I was, thinking that I knew everything that was relevant to her health, and I didn’t know this huge part of her—not because she was unwilling to tell me but because I hadn’t thought to ask.”
With that, Schulman became an advocate for abuse survivors. First, he altered the patient questionnaire used at Lankenau, adding direct questions about physical, sexual and emotional abuse. “Every week, two or three patients tell me that they’ve been abused,” Schulman says. “I was shocked at those numbers. I’m ashamed to say that I didn’t know how prevalent abuse is. Some patients have it in their history. Some are currently in abusive relationships, and we get those patients immediate counseling. Past or present, the abuse can have very real medical ramifications. Knowing about it allows me to alter treatment modalities to include talk therapy, antidepressants and other options.”
Schulman set out to share the information with other neurologists. In 2010, he met Dr. Anna Hohler, a Boston Hospital neurologist with a long-held interest in helping women with a history of domestic violence. Together, Schulman and Hohler came up with the American Academy of Neurology’s new position statement, advising that patients should be screened for abuse at every appointment.
The next step was to reach beyond neurologists and share the information with all doctors—the vast majority of whom have no training in dealing with abuse. With the new HealtheSAVE app (“SAVE” is an acronym for “Stopping Abuse, Violence and Exploitation”), Doctors [can] discreetly access vital information on their phones while sitting with the patient.
Schulman and Hohler collaborated with a psychiatrist, a pediatrician and a patient-safety advocate on material for the app, which provides physicians with screening guidelines, local resources, support services and other information. Berwyn-based healthcare consultant James Manousos built HealtheSAVE, which won fourth place and $2,500 in 2012’s “Ending Violence @ Home App Challenge,” an international competition sponsored by the Institute of Medicine and the Avon Foundation for Women.
“We’re talking to people about adapting this for Africa because of the even higher prevalence of domestic violence there and the severity of it,” says Manousos. “The money the app generates will fund shelters throughout this country and other countries, and fund education for doctors to be trained in abuse awareness.”
Because, as Schulman says, “When it comes to abuse, doctors don’t have to be experts. But we do have to be advocates.”