General Excellence

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.

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.

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