Family Violence Education in Medical School-Based Residency Programs -- Virginia, 1995

In the United States, family violence (e.g., intimate partner violence, child abuse, and elder abuse) is a well-documented social and public health problem that physicians are uniquely positioned to play a crucial role in addressing (1,2). However, few schools of medicine or residency training programs provide substantial attention to family violence in their curricula (3-5). To assess the status of graduate medical education regarding family violence at Virginia's three medical schools (Eastern Virginia Medical School {EVMS}, Medical College of Virginia {MCV}, and the University of Virginia {UVA}), the Task Force on Violence Education and Awareness for Physicians, established by the Virginia Commission on Family Violence, conducted a survey of these medical schools in 1995. This report summarizes the results of the survey, which identified variations in the formal programs to address family violence at these schools.

The task force distributed questionnaires to directors of the 69 fully accredited medical school-based residency programs in the three schools (EVMS, 20; MCV, 29; and UVA, 20) asking them to indicate the presence in the curriculum of instruction on specific types of family abuse and sexual assault, to indicate whether such teaching was required or elective, and to describe materials and methods used in the curriculum. In addition, the directors were asked to identify faculty at their institution who were experts in the area of family violence and to list the area of their expertise. To increase the likelihood of response to the survey, respondents were informed that only aggregate results would be reported. Therefore, program-specific findings are not included in this report.

Of the 69 residency programs surveyed, 48 (70%) responded. Of the 48, a total of 26 (54%) indicated they included content related to family violence in their curricula. A total of 20 (42%) covered child abuse (the content area most frequently covered), 13 (27%) covered battered women, and nine (19%) covered elder abuse.

Whether instruction courses were required or elective varied substantially among the programs. Sixteen of the 20 programs that provided some instruction on child abuse had required courses, as did 10 of the 13 programs that covered battered women and seven of the nine programs that covered elder abuse. In addition, the instructional methods for the existing curricula varied; they included regularly scheduled grand rounds on family violence topics, occasional discussion of these topics as part of "noon" conferences, informal instruction from attending physicians during rounds, and "brown bag" series discussions and presentations.

Of the 27 experts on family violence identified, 16 had expertise in identifying and treating family violence-related injuries. Other areas in which experts were identified included child abuse, elder abuse, violence against women during pregnancy, post-traumatic stress disorder in children, and community response to violence. No expert was identified in the areas of mental health sequelae of family violence, transgenerational transmission of violence, and violence prevention.

Reported by: MK Hendricks-Matthews, PhD, Dept of Preventive Medicine and Community Health, Medical College of Virginia/Virginia Commonwealth Univ, Richmond. Div of Violence Prevention, National Center for Injury Prevention and Control, CDC.

Editorial Note

Editorial Note: Victims and/or witnesses of family violence seek care in all medical settings more often than do persons without such a history (6), overuse medical services (7), and may be aided through intervention by physicians (1,2). For physicians to intervene, however, they must be adequately trained to identify victims and potential victims of abuse, help them receive treatment, understand the deleterious effects of violence, teach patients about violence prevention, and become comfortable with their role as collaborators with professionals from other disciplines who deal with violence. Although physicians are recognized as having critical roles in this arena, the findings in this survey and others (3,4) indicate that instruction about family violence is still limited and without standardization. The findings in this analysis of medical schools in Virginia is consistent with training offered in most medical schools and residency programs (6).

The results of the survey described in this report are subject to at least three limitations. First, no attempt was made to contact nonresponding residency programs; survey responses from those programs could have differed from those that did respond. Second, the survey did not have precise criteria for defining presence of family-violence instruction in program curricula (e.g., the amount of time spent teaching specific areas of family violence), which could have resulted in overestimating the amount of family-violence curricula in place. Finally, no assessment of the quality of curricula was made.

The task force used results of this survey to develop five recommendations regarding medical education about family violence in Virginia (8): 1) formally integrate family-violence curricula into medical school and internship/residency programs; 2) use model curricula developed nationally as a base for training programs; 3) develop an in-school assessment tool to track each school's efforts; 4) have the medical schools, the commission, and the state medical society jointly sponsor a statewide medical-education conference for faculty and other interested persons; and 5) develop statewide mechanisms to coordinate family-violence prevention services available through medical, legal, judicial, social services, political, and business agencies and services. These recommendations were adopted by the commission and presented in a report of the commission to the governor and the 1996 General Assembly of Virginia; the General Assembly accepted the recommendations and agreed to continue support for the commission's activities. In addition, the deans of the three medical schools agreed to collaborate on efforts to more thoroughly and systematically integrate violence education into their residency programs and to develop longitudinal, multidisciplinary instruction at the predoctoral level.

In U.S. medical schools and residency programs, family violence education in the curriculum often is brief and not reinforced in residency programs. Most hospitals do not have programs or policies to train and support physicians for work with abuse victims. The study in Virginia illustrates the need for a nationwide assessment of curricula and faculty development in medical school and residency programs and creation of an ongoing reinforcement protocol throughout the health-care system, with evaluation instituted at all levels within each program. CDC is developing an annotative bibliography of training programs to assist medical training programs, health-care organizations, and advocacy groups in identifying curricula and protocols. A framework for evaluating these programs also is being developed. Both will be available from CDC's National Center for Injury Prevention and Control in the spring of 1997.

References

1. Hendricks-Matthews M. Family physicians and violence: Looking back, looking ahead. Am Fam Phys 1992;45:2033-5.

2. American Medial Association. Family violence: building a coordinated community response -- a guide for communities. Chicago, Illinois: American Medical Association, 1996.

3. CDC. Education about adult domestic violence in U.S. and Canadian medical schools, 1987-88. MMWR 1989;38:17-9.

4. CDC. Violence education in family practice residency programs -- United States, 1989. MMWR 1991;40:428-30.

5. Alpert EJ. Making a place for teaching about family violence in medical school. Acad Med 1995;70:974-8.

6. Goldman LS, Horan D, Warshaw C, Kaplan S, Hendricks-Matthews M. Diagnostic and treatment guidelines on mental health effects of family violence. Chicago, Illinois: American Medical Association, 1995.

7. Koss MP, Koss PG, Woodruff WJ. Deleterious effects of criminal victimization on women's health and medical utilization. Arch Intern Med 1991;151:342-7.

8. Hendricks-Matthews M (chairperson). Task Force on Violence Education and Awareness for Physicians: report and recommendations. Richmond, Virginia: The Virginia Commission on Family Violence Prevention, 1995.

   
   

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