ANNUAL FEATURE: IN PROGRESS: REPORTS OF NEW APPROACHES IN MEDICAL EDUCATION: CURRICULUM: Hot Topics
Objective: Domestic violence is a multifaceted problem affecting women and some men at alarming rates. Physicians are in key positions to uncover domestic violence, yet patients often present repeatedly to medical providers before, if ever, the “diagnosis” is made. Can we prepare medical students to detect domestic violence and identify potential barriers to making this diagnosis? Can role analysis aid in understanding the responsibilities and pitfalls of the doctor in “diagnosing” and “treating” domestic violence? These key questions form the backdrop for the seminar held in preparation for clinical medicine.
Description: The inclusion of a “domestic violence standardized patient” in the third-year preparation course for clinical medicine affords us the opportunity to develop a model of analyzing the power relationships operative in domestic violence. After each student has the opportunity to be videotaped in an interview with the patient, the small group of about 20 students reviews the experience. Many barriers are noted, both from the patient's side and the student's side: denial of the problem, lack of understanding and adequate language to address the issues beyond the medical, feelings of disgust and distance, desire to rescue, inability to connect with the patient. Then the group is split into three subgroups, each given the task of describing the roles of the three key players: the victim, the perpetrator, and the doctor. The whole group reconvenes to share the profiles and put them in relationship with each other.
Early in the directed discussion, the students realize that power is the central negotiator between the perpetrator and the victim. These two poles, held fast together by power—akin to covalent bonds—are written on the board. The faculty and students proceed to describe the roles based upon the psychosocial profiles: similarities (such as low self-esteem, depression and often substance abuse, childhood violence, and learned behavior) as well as differences (dominance and submission, dependence and independence) are noted. The faculty describe a co-dependent dynamic: an authoritarian relationship revolving around power, anchored in the primitive defense mechanisms of denial and projection.
Then, the group analyzes the middle role of the doctor: to listen, to pose questions, to validate feelings, to encourage voice, to be a resource, to question the normalcy of violence. In response to the desire to “rescue” the victim from a potentially lethal situation, the group refers again to the diagram of the power relationship. They analyze the consequences of an external person destabilizing the power relationship: safety issues for the doctor and the victim, and the potential for a new co-dependent relationship between the doctor and the victim. It becomes clear that the only thing the doctor can “do” is to empower the patient through trust and connection.
Discussion: Using standardized patients to portray domestic violence signals an important step in teaching clinical medicine. To teach effective “treatment,” however, reflection and analysis of the power relationships are essential teachable skills. Then the real power in the doctor—patient relationship becomes clear: to enable through empowerment, unified in the Spanish noun/verb for power: poder.
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