AMA Journal of Ethics^®

Intimate partner violence (IPV) leads to physical assault in more than 25 percent of women and nearly 10 percent of men over the course of their lives. Its health consequences are far reaching and include acute injury and death, as well as long-term sequelae such as mental health problems and decreased self-care that can cause chronic disease and exacerbation of chronic disease. Not surprisingly, research has shown that physicians who receive specific training in IPV are more likely to screen for it—making teaching about IPV a priority for medical education [1-3].

Educating medical students about IPV presents many challenges. Because IPV is a complex psychosocial phenomenon, it does not readily fit into either discipline- or disease-based models for preclinical instruction, or into discipline-based instruction during the clinical years. With many topics competing for scarce curricular time, it is especially difficult to insert a subject that is not seen as belonging to a particular discipline. The number of students who think that knowing about IPV will be highly relevant to their practices has been shown to decrease over the course of medical school, even when IPV is part of the medical curriculum. A survey of graduating U.S. medical students revealed that, although 80 percent believed they received adequate training in IPV, only 35 percent expected that such training would be relevant to their practice [1, 3].

IPV Education at UCLA

California law requires that medical students and physicians be educated about IPV [4]. And the state's penal code requires that health practitioners report having provided medical services to a patient who they reasonably suspect is suffering from a wound or other physical injury caused by assault or abusive conduct [4].

Faculty at the David Geffen School of Medicine at UCLA have faced several challenges in their attempts to ensure adequate instruction in IPV for all students. UCLA limits contact instructional hours in the first 2 years to no more than 24 hours per week, setting a high premium on contact-hour time. During the clinical years, students train at many facilities, making it difficult to standardize the instruction all students receive as they rotate through a particular clerkship. The patient population and the medical student body are among the most racially and ethnically diverse in the nation, which creates both opportunities and hurdles to training students about IPV.

The educational demand has been tackled in three ways, by: (1) imbedding IPV curriculum into an established course on psychosocial issues in the first 2 years, (2) promoting a strong institution-wide approach to patients affected by IPV to shape the environment of the clinical years, and (3) supporting and evaluating elective experiences in IPV for interested students.

Approach to Teaching Mandatory Reporting

Patient-physician confidentiality is an ethical and federally legislated cornerstone of medical student education. The fact that mandatory reporting in California specifically supersedes this principle often generates student inquiry. It is helpful to note that other legally mandated reporting also displaces the right to patient privacy; laws require reporting of child abuse, elder abuse, sexual assault, impaired drivers, and certain sexually transmitted and other infectious diseases [5-7]. To comply with mandatory reporting, medical workers must fill out a written report and notify law enforcement by telephone. One study of this practice demonstrated that police respond only upon telephone notification. This may allay student fears that law enforcement will act on the written report at a time that would be unpredictable to the victim and medical personnel [8].

Much controversy surrounds reporting obligations as they relate to IPV. Opponents of medical reporting surmise that it may cause injured patients to avoid seeking medical care out of fear that police involvement could anger a perpetrator and increase his or her aggression [9]. Students should also be told about the potential positive aspects of mandatory reporting; it can result in timely and appropriate law-enforcement involvement, which, when combined with social and advocate support, can prevent further injury to the patient by providing immediate perpetrator arrest or facilitating safe shelter placement for the victim.

It is key to stress that mandatory reporting of suspicious injuries applies to only the small subset of patients suffering from IPV who go to physicians for medical treatment with acute injuries. Physicians assist most IPV victims through identification, treatment, and advocacy referral without the immediate involvement of law enforcement.

Preclinical Training

At UCLA, the preclinical IPV curriculum is imbedded in the Doctoring course, which became mandatory in 1993. It teaches medical students culturally sensitive patient communication and clinical problem-solving skills, health promotion and disease prevention, implications of financial and access issues, and medical ethics. Students work in small groups with tutors who are practicing physicians or other health professionals, such as psychologists and medical social workers.

During the first year of Doctoring, all students are introduced to the IPV curriculum, which consists of a standardized patient (SP) case, discussion points, and handouts detailing the domestic violence and child-abuse reporting laws in California. The case's learning objectives are to: (1) be able to conduct a culturally sensitive, empathic history, (2) know how to help the patient develop a safety plan, (3) be aware of mandatory reporting requirements in California, (4) be aware of local resources available to survivors of violence, and (5) understand a survivor's perspective in an abusive relationship and the barriers to his or her seeking help.

Students interview an SP in front of 8 or 9 students. The SPs at UCLA are actors who memorize a script, so their answers are consistent with the learning objectives of each SP case. SPs are trained to demonstrate a reluctance to disclose violence, fears of spousal repercussions, and concerns about privacy of information. The SPs will not reveal the information unless the students both clearly address confidentiality and reporting requirements and take steps to make the SP comfortable with disclosing abuse to the interviewer.

To conduct the interview, students are presented with the case's facts—a 48-year-old female who arrives at a walk-in doctor's appointment complaining of a headache and is found to have facial contusions and an injured arm. Students have access to the patient's medical record, which documents two visits to the emergency department for injuries (hand laceration and broken ribs that the patient described as accidents) along with three prior clinic visits for vague abdominal complaints over the past 18 months.

The class discussion covers: (1) how medical records can be used to establish a pattern of violence, (2) the importance of establishing a safe environment when questioning a potential IPV survivor and honestly disclosing reporting requirements, and (3) using structured questions to gather information from the patient. Equally important, especially in a culturally diverse city such as Los Angeles, is preparing students to be culturally sensitive during the interview. Students discuss differences in culture such as who is considered head of the family, male and female roles in the family structure, potential risks in separation or divorce, and how these may differ depending on the cultural beliefs of the patient and community in which they live. The case concludes by referring the patients to the appropriate resources to remove them from the abusive situation and the students completing a report for law enforcement as mandated by California law.

Clinical Training

As is true at most medical schools, clinical training in IPV at UCLA depends on students' clinical and didactic experiences during specialty-based rotations. Primary care and emergency medicine departments have didactic training on IPV as part of regular lectures, but whether students attend them depends on whether or not they are rotating at the times that the lectures are given.

Students who encounter victims of IPV have access to cross-disciplinary resources. The UCLA Domestic Violence Committee meets quarterly to review IPV cases to improve the quality of care IPV patients receive. The committee consists of the local shelter advocates as well as volunteers from the faculty and staff of the medical center including physicians, dentists, nurses, and social workers. UCLA partners with a well-established community provider of IPV services to identify an on-call advocate who can talk with patients and go to the emergency department or medical center if the patient is in an acute crisis. Access to shelter services and immediate counseling are available through the on-call advocate.

Elective Experiences

Students have the opportunity to participate in the Adolescent Relationship Violence Prevention selective offered at the David Geffen School of Medicine at UCLA, which combines didactic training with experiential outreach training. Students are trained in the Peace Over Violence “In Touch with Teens” adolescent-dating, violence-prevention curriculum, and teach local high school teens how to prevent teen-dating violence through the use of conflict-resolution skills. The primary partner for the program is the Los Angeles Unified School District (LAUSD), the second largest school district in the nation whose student body reflects the ethnic and racial diversity of Los Angeles.

In addition to curriculum training and outreach experience, sessions address culture as it relates to domestic violence. The program provides mentoring opportunities for both trainers and participating teens.

The program evolved into a medical school selective offered for credit in 2004. From 2005 to 2006 the U.S. Department of Health & Human Services funded its implementation and evaluation at four U.S. medical schools. Results showed not only that the didactic portion of the training significantly improved students' knowledge of teen IPV issues, but also that the addition of experience as community educators improved confidence in recognizing forms of abuse, discussing the magnitude of the problem and partner abuse, helping the abused person explore his or her beliefs, and offering resources for referral [10].

As another selective, the American Medical Women's Association (AMWA) chapter organizes an annual Domestic Violence Week. Local organizations, such as Los Angeles' Peace Over Violence lecture on the psychosocial theories of IPV, epidemiological spectrum of victims, and resources available for both the victims and perpetrators of abuse. Victims give testimonials on their experiences. An estimated 150 to 200 students attend over the 5 days. The goals of the program are to educate and inspire students about IPV and the problems it causes within society.

Cultural Competency

Culture-specific factors play a significant role in IPV. As part of the selective, medical students were asked to explore potential barriers as educators and review data relevant to racial, cultural, socioeconomic, educational, and gender differences in IPV. Students examine their own biases and stereotyping of adolescents of different cultural, socioeconomic, and racial backgrounds.

After didactic training, students demonstrated a statistically significant improvement in their understanding of disparities of care for non-English speaking patients, and the role of primary care in reducing disparities. They were also more aware of the phenomenon of increased patient satisfaction when patients were matched to physicians of the same racial and ethnic background as their own. Students showed greater knowledge of disease-specific disparities.

After the students' community experiences, they endorsed greater understanding of barriers to communication between themselves and individuals with different language and racial, ethnic, or educational status, which suggests that community experiences may help them understand culture- and ethnicity-related barriers to patient care.

Conclusions

The presence of a multidisciplinary course dedicated to teaching medical students culturally sensitive patient communication and clinical problem-solving skills, health promotion, disease prevention, implications of financial and access issues, and medical ethics has allowed UCLA to integrate information and training about IPV into its curriculum. Inclusion of information about California law on mandatory reporting has been a key part. The use of standardized patients ensures that all medical students have experience with appropriate interview and counseling techniques for patients who may be victims of IPV.

A randomized study of a selective course developed at UCLA that trains medical students to counsel adolescents about IPV prevention showed that community outreach experience improves students' confidence in dealing with IPV in clinical situations. Didactic and community experiences may also enhance their cultural sensitivity. Although students have significant resources available during clinical rotations to assist victims of IPV, and although primary care and emergency medicine departments include IPV in their postgraduate clinical curriculum, ensuring that all medical students revisit IPV issues during their clinical years remains a challenge at UCLA.