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March 1, 2000

Helping Medical Students Help Survivors of Domestic Violence

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JAMA. 2000;283(9):1199. doi:10.1001/jama.283.9.1199-JMS0301-3-1

Survivors of domestic violence generally perceive their health to be poor. They visit physicians twice as often as patients without a history of abuse, often presenting with complaints, such as chronic pain and irritable bowel syndrome, unrelated to trauma.1 In a recent study of women seeking emergency care, the prevalence of ongoing domestic violence was found to be 12%. Sadly, only 2.6% of these patients were screened for domestic violence.2

Growing awareness of the scope of domestic violence has spawned efforts to expand relevant curricula in medical schools, but progress has been uneven. While the number of medical schools requiring education on intimate partner violence increased by 18% over the last 7 years,3 instruction still primarily occurs during the preclinical years and is often forgotten on the wards.4

Why have physicians been so slow to incorporate education on domestic violence into the clinical years? In addition to concerns about crowded medical curricula, some medical school faculty feel that adding domestic violence awareness is useless if there are "nothing but impotent solutions" to the problem.5 To be effective, an intimate partner violence curriculum should be concise and should highlight the effectiveness of intervention.

The University of Massachusetts School of Medicine recently designed a third-year "inter-clerkship" that seems to satisfy these criteria. Over 3 days and between other required clerkships, students listen to the stories of domestic violence survivors, role play how they might identify and give appropriate assistance to those at risk, and discuss and reflect on their own experiences with family violence. This approach seems to produce sustainable improvements in the attitudes and skills necessary for violence screening and intervention,6 but other schools have been slow to follow suit.

Additionally, there may be resistance to involving medical students in the care of survivors. During my obstetrics and gynecology rotation, I was counseled to limit my interactions with a sexual assault survivor who had suffered a vaginal laceration. The reasoning was that the resident needed to see all of the student's patients, and the effect of including a student would be to double the amount of intrusion on the patient. While a patient's request to limit the number of providers should be respected, such a wish should not be assumed. In some cases, excluding a medical student might limit the amount of sensitive care provided a patient who needs it most.

The role of medical students in caring for survivors of violence should be expanded for 3 reasons. First, third-year medical students are routinely expected to elicit complete and detailed histories. Questions about current or past exposure to violence can be incorporated in a medical student's interview along with questions about smoking, diet, and exercise. Second, unlike busier residents who may feel pressured to take more focused histories, medical students can take time to discuss with sensitivity whatever issues may arise. Early and thorough discussion of a traumatic event may reduce the severity of posttraumatic stress disorder.7

Finally, the time pressure in clinic settings often pushes experienced clinicians into maintaining control of the clinical interview. Such interactions can reinforce an abused patient's expectations of unbalanced power dynamics.4 Medical students, at the bottom of hospital power structures, may be well suited to provide victims a sense of equality, safety, and empowerment that are crucial to the healing process.

The prevalence of ongoing or past family violence among medical students, about 38%, mirrors that of the general population.8 An important but often overlooked obstacle to providing effective care to those violated is the disruptive and painful emotional response that eliciting a painful history can evoke, particularly in students who were or are themselves violated. Such students will need the support of understanding instructors and advisors if we are to expect them to give support to patients with similar life histories.

An effective response to victims of partner violence requires thought and action outside of traditional biomedical models. Eliciting a history of domestic violence is much more than collecting information and identifying cases—it can be, in itself, a potent intervention.4 Similarly, educating medical students about domestic violence requires not a traditional didactic model, but one in which students interact with survivors of domestic violence and discuss their feelings and responses to such interactions. Such an integrative model can help us shape the tools to effectively care for survivors of domestic violence.

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