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Domestic Violence

OVERVIEW

Violence and abuse are among the greatest threats to the public health and safety facing our nation today. Episodes are widespread throughout society and come in many forms and occur in many places. Violence and abuse cause an enormous amount of illness, suffering, dysfunction, lost productivity, injuries, and death. As physicians, we have an obligation to our patients and our communities to become involved in our roles as health providers and as advocates.

In 2002 the Institute of Medicine released a report examining the education of physicians on domestic violence. It called for development of experts in this field and federal funding of centers of excellence in the area of domestic violence research and education. There is a growing consensus among organizations of physicians that a fundamental change in the way physicians understand, respond to, and participate in the prevention of, violence and abuse must occur. Change must come at the core of education to gain the greatest understanding of a complex issue. More research is needed, as are strategies for translating emerging medical and public health science to practice.

Many sectors of society must contribute in order to abolish violence and abuse. For while we cannot be expected to abolish violence and abuse solely through our efforts, neither can it be accomplished without us. We must not be the weak link in that process.

TOPIC LEARNING GOALS AND OBJECTIVES
(Organized by ACGME Competencies)

Patient Care

GOAL: Students will recognize that domestic violence occurs in all groups within society and that all physicians must be alert to this problem when treating patients in all medical care settings.

OBJECTIVES: Students will be able to:

• Recognize the significant physical and mental health effects of both ongoing and prior family violence.
• Recognize the effects of family violence across the lifespan, including the long-term effects on children who are exposed to family violence.
• Recognize intentional injury patterns.

GOAL: Students will be able to care appropriately for victims and perpetrators of domestic violence and make appropriate referrals when indicated.

OBJECTIVES: Students will be able to:

• Demonstrate competency in routine screening for family violence across the lifespan, using culturally and developmentally appropriate communication techniques, including direct and indirect screening questions and instruments.
• Assess for physical and/or mental health effects persisting into adult life, after childhood experience of abuse or family violence.
• Assess for adverse health effects of present and past violence.
• Assess risk of severe injury or death in a patient presenting with family violence-related injuries and illnesses.
• Provide safety planning for a victim of intimate partner violence.
• Refer victims and survivors of family violence to the appropriate community agencies, social workers, or resource specialists in family violence, as indicated.
• Assist the patient with understanding the relationship of violence and abuse to their health problems.
• Provide culturally competent assessment and intervention.
• Document extent of current and prior injuries through written documentation, use of body maps, and/or photographs.

Medical Knowledge

GOAL: Students will understand the epidemiology and the medical consequences of domestic violence.

OBJECTIVES: Students will be able to:

• Explain the prevalence of family violence in all its forms, including child physical, sexual and psychological abuse and neglect; intimate partner violence; teen dating violence; date rape; and elder abuse and neglect.
• Compare and contrast risk factors for becoming a victim versus a perpetrator of family violence.

Practice-Based Learning and Improvement

GOAL: Students will understand the evidence for universal screening and how this can impact patients, a practice, and a community.

OBJECTIVES: Students will be able to:

• Identify screening methods that can be used by a primary care physician in a physician's office to detect domestic violence.
• Describe how screening can lead to improved patient care outcomes.

Interpersonal and Communication Skills

GOAL: Students will be able to communicate with victims and perpetrators of domestic violence in a manner that is objective and supportive of the physician-patient relationship.

OBJECTIVES: Students will be able to:

• Demonstrate, by acknowledging and intervening, the ability to communicate nonjudgmentally and compassionately with victims and survivors, and perpetrators of family violence.
• Communicate in the medical record and verbally in a manner that is respectful and nonpejorative, does not blame the victim, and recognizes the perpetrator's responsibility for violence.
• Recognize that cultural factors are important in influencing the occurrence and patterns of and responses to family violence in individuals, families, and communities

Professionalism

GOAL: Students will know the laws and their ethical obligations concerning violence and confidentiality.

OBJECTIVES: Students will be able to:

• List state reporting requirements for child abuse, intimate partner violence, elder abuse, abuse of vulnerable adults, and assault with a weapon.
• Describe the ethical principles that apply to patient confidentiality for victims.

GOAL: Students will be aware of their own attitudes and feelings concerning violence.

OBJECTIVES: Students will be able to

• Recognize their own attitudes and feelings about family violence, including the possibility of their own as well as friends' or family members' victimization and the need to address ongoing issues arising from such experiences.
• Recognize the potential for abuse in the medical workplace and in the educational process.

Systems-Based Practice

GOAL: Students will understand the impact of domestic violence on patients, a practice, and a community, recognizing it as a health care issue.

OBJECTIVES: Students will be able to:

• Outline the physician's role in promoting activities to address prevention with populations at risk (e.g., child witnesses, pregnant women, and dependent-frail elderly).
• Know appropriate methods for collection and documentation of evidence so that both the patient and the provider are protected.

EDUCATIONAL METHODS AND RESOURCES

Clinical Experience

• Working with community advocates
  
• Observations of interviews that involve victims or perpetrators
  
• Observations of care in community resources for violence and abuse
  
• Participation in patient education activities in community health settings (value-added activity)

Independent Learning

• Journaling in conjunction with observations of interviews

Small-Group Learning

• Case-based discussions or PBL cases
  
• UCSF Bill Shore, MD and Umass ( Mark Quirk, EdD) Intersessions
  
• Doctoring Curriculum (UCLA, Rich Usatine, MD)

Problem-Based Learning

• PBL Case from Caryl Heaton, DO, RWJ-UMDNJ

Curricular Resources

• HP 2010 Objectives and overview
  ( online slide presentation )

Lectures

• Lecture by David Schneider, MD

Web Sites

• Family Violence Prevention Fund
  http://endabuse.org/
• American Academy of Family Physicians listing of policies and links on domestic violence
  http://www.aafp.org/x24009.xml
• To provide concrete guidance to communities, policy leaders, and individuals engaged in activities to end violence against women, the National Advisory Council on Violence Against Women developed the Toolkit To End Violence Against Women. The recommendations contained in the Toolkit were reviewed by numerous experts in the fields of sexual assault, domestic violence, and stalking.
  http://toolkit.ncjrs.org/default.htm

Contact People

• STFM Group on Violence Education and Prevention
  
• AMA information on Violence Prevention

Other

Teaching Strategies

• Case-based learning using case discussions or simulated or actual patient interviews
  
• Case-based lectures and case-based learning using video productions
  
• Visiting community sites such as women's shelters and meeting with violence advocates
  
• Web-based cases
  
• CD-ROMs and DVDs for self-directed learning

Integration Strategies

• Interview training utilizing affected individuals

ASSESSMENT STRATEGIES

• OSCE/SP to assess attitudes and interview skills
  
• Objective Testing/objective testing with visuals
  
• Observation
  
• Diaries identifying barriers and how these were approached
  
• Creation of short reports after observations and self-directed learning
  
• Exit interviews with patients/families re: effectiveness of student patient education

Lead Author: David Schneider, MD
Clerkship/Post-Clerkship Workgroup members: Ann O'Brien-Gonzales, PhD (Chair), Alexander Chessman, MD (EC Liaison), Caryl Heaton, DO, Janice Nevin, MD, MPH, Lauren Oshman, MD, Deborah McPherson, MD, Mark. E Quirk, EdD, David Schneider, MD, MSPH, William B. Shore, MD, Richard Usatine, MD

Family Medicine Curriculum Resource (FMCR) Project HRSA Contract 240-00-0107.

Revised November 6, 2003

For questions or comments, please contact Webmaster or Ardis Davis

This page last updated October 15, 2005