Freedy, John R. PhD; Monnier, Jeannine PhD; Shaw, Darlene L. PhD
Dr. Freedy is a second-year medical student; Dr. Monnier is assistant professor, Department of Psychiatry and Behavioral Sciences; and Dr. Shaw is associate professor, Department of Psychiatry and Behavioral Sciences; all at the Medical College of South Carolina, Charleston. Both Dr. Freedy and Dr. Monnier completed National Institute of Mental Health fellowships concerning the mental health effects of violence on children and adults.
Over the past ten to 15 years, individual educators and several collective bodies have recommended that education about violence be integrated into medical training,1–4 and papers describing curricular approaches to violence education have started to appear. Examples of curricular efforts include a multidisciplinary elective course for first-year medical students,5 a problem-based learning module on domestic violence for second-year students,6 an intensive interclerkship on domestic violence for third-year students that improved students' attitudes, knowledge, and skills concerning violence,7 and methods for promoting the development of faculty expertise in the area of family violence.8 While these efforts are important and have obvious strengths, all occurred at different institutions and many focused on one area of violence only (e.g., domestic violence). Thus, existing curricular approaches fall short of what we believe must be undertaken: the integration of comprehensive violence education into all levels of medical education.
Change in any area of professional training and practice often comes slowly. This appears to be the case for incorporating comprehensive violence education throughout medical training. Why is change in this area of medical education and practice not occurring more rapidly? DeLahunta and Tulsky found the following reasons for resistance to domestic violence curricula when examining open-ended comments in a survey of medical faculty and students: (1) limited curricular time with other “more important” topics to be covered; (2) the view that violence is a non-medical issue; (3) ambiguity in the definition of abuse; and, (4) lack of available solutions to address discovered domestic violence.9 Although these authors acknowledged that the majority of those surveyed believed that education about domestic violence was important, they suggested that faculty and student attitudes and ambivalence toward the topic need to be addressed more openly if needed curricular changes are to be made.
OVERCOMING THE OBSTACLES
The four perceptions identified by deLahunta and Tulsky—that violence is not a high-priority topic given the overcrowded curriculum; that violence is a non-medical issue; that the terms used to discuss issues of violence are too ambiguous; and that there are inadequate resources available to physicians for helping victims of violence—present obstacles that must be overcome if comprehensive violence education is to become a reality. Below, we address them.
Curricular priorities. Everyone agrees that instructional time is limited and that it is necessary to prioritize what can reasonably be covered within a medical curriculum. However, the scope of violence in our society is so broad and the physical and mental health effects of violence are so profound that comprehensive violence education must be addressed at all levels of medical training. A variety of well-designed community-based studies suggest that somewhere between 40 and 70% of adults will directly experience at least one violent event in their lifetimes. Resnick and colleagues10 conducted intensive structured interviews with a national probability sample of 4,009 adult American women and found the following lifetime rates for violence exposure: 68.9% had experienced at least one violent event, 35.4% had been victims of at least one of four violent crimes, and 12.6% had been victims of completed rapes. Given these numbers, medical educators cannot in good conscience say that comprehensive violence education cannot be included in the curriculum.
Violence as a medical issue. Available evidence supports the assertion that violence must be considered a medical issue. Violence is associated with a number of acute and potentially chronic psychological problems, including posttraumatic stress disorder, major depressive disorder, alcohol abuse, drug abuse, and suicide.11,12 Select findings from studies of student samples also include more frequent suicidal thoughts among medical students with histories of family violence,13 increased rates of drug and alcohol abuse among college students with histories of sexual or physical abuse,14 and lower sexual self-esteem among college women who have been raped.15
Resnick and colleagues12 reviewed physical outcomes associated with interpersonal violence. These were among the more remarkable findings: 5% of rape victims annually (approximately 32,000 women) become pregnant as a result of rape; more than half of rape victims seen in emergency rooms have vaginal and perineal tearing, and 15% have significant vaginal tearing; 3 to 30% of rape victims acquire sexually transmitted diseases other than HIV infection (this rate of STDs is significantly higher than that among women who have not been raped); rape victims report substantial fear of contracting HIV infection (actual transmission rates from rape are exceedingly low); and there is a significant association between violent events and irritable bowel syndrome, chronic pain syndromes, sexual dysfunction, and reproductive health problems. In their literature review, these researchers also documented the following indirect health effects associated with exposure to violence: alcohol abuse, cocaine abuse, cigarette smoking, health care neglect, risky sexual behaviors, and eating disorders.
Defining violence. It is important to clearly define what is meant in referring to violent or traumatic events. Standardized definitions for violent or traumatic events have been developed for use in both clinical and research practice.16 Such standard definitions are the basis of the previously cited research findings concerning the high prevalence rates for violence and associated negative psychological and physical health outcomes.11,12 In short, the position that violent or traumatic events are too poorly defined to be addressed within medical curricula is simply incorrect.
Clear definitions of violence have led to the availability of brief screening instruments for use in clinical settings. Medical students and practitioners must be taught how to effectively use these screening tools with their patients. Any complete history for a child or an adult patient should include a number of basic questions regarding recent and past violent or traumatic experiences. At least two studies have demonstrated the value of brief violence-screening questionnaires in clinical settings. Saunders and colleagues17 found that the addition of a brief violence-screening questionnaire to the standard history interview at a community mental health center substantially improved the identification of exposures to violence. We added a brief violence-screening questionnaire to the standard history-taking procedure at the Medical University of South Carolina. Use of this questionnaire led to increased identification of victims of violence. For example, before the screening tool was introduced, the rate of identified sexual assault (lifetime prevalence) was 5.5%; after we added the screening tool, the identified rate was 19.6%. In addition, we demonstrated that higher rates of violence exposure were associated with clinical levels of psychological distress and alcohol abuse.18
Availability of Solutions and Resources. Contrary to the perceptions of many physicians, many resources are available to address the adverse outcomes created by exposure to violence. Some of these approaches are clearly within the realm of medical practice. At a minimum, appropriate physical care can be provided to patients who are victims of violence. Further, a compassionate and nonjudgmental attitude can go a long way towards eliciting needed information, minimizing psychological damage (e.g., a rape victim feeling blamed or judged), and encouraging compliance with follow-up plans. The physician is also in a position to provide appropriate referrals for needed services. Such referrals might include medical follow-up, individual or group counseling, emergency shelters, social services, clergy, police, and legal services, among others.
Violence is an important medical issue that deserves additional attention in the medical curriculum. The prevalence of violence and related negative mental and physical health outcomes support this assertion. Required violence education should begin during the basic science years in such courses as physical diagnosis, psychiatry, and behavioral sciences, or through other venues such as problem-based learning modules. In the clinical years, each required rotation should include appropriate educational experiences related to the medical aspects of violence, as is likely that violence will be a significant issue for at least some patients in all of these services (i.e., family medicine, internal medicine, obstetrics—gynecology, pediatrics, psychiatry, and surgery). In addition, concentrated interclerkship experiences concerning medical aspects of violence might be required of all third- and fourth-year medical students. Faculty education and development regarding violence can occur through a range of mechanisms (e.g., self-study, grand rounds, professional consultation, CME).
The incorporation of comprehensive violence education into medical curricula is an obtainable goal. At the most basic level, medical educators must recognize that violence education is essential to comprehensive and competent medical care. Simple assessment procedures are available to ascertain patients' exposures to violence and screening for recent and past violence exposures should be routine for patients of all ages. Physicians can address treatment needs and make appropriate referrals when they have been taught what to do and what resources are available to them. Early and ongoing medical education is necessary to build lasting competence in assessment, treatment, and referral for victims of violence.
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