Nancy J. Baker

Strategic footholds for medical education about domestic violence.

The author describes in detail the successful education initiatives on domestic violence, especially violence against adult women, that have been implemented for family medicine residents at the St. Paul-Ramsey Medical Center in St. Paul, Minnesota, and for medical students at each of the three Minnesota medical schools. For example, in 1990 the residency program adopted a community-oriented primary care approach to teaching and clinical activities, including the area of domestic violence. This approach stresses partnerships with community organizations that deal with domestic abuse. Also developed was a curriculum to help residents deal with their apprehension about domestic violence and acquire the knowledge, attitudes, and skills they need to confront this problem effectively. At the three medical schools, teaching about domestic violence takes place in preclinical courses, during clinical rotations (where students work with abuse victims), and through extracurricular activities. The author describes some important types of resistance to having instruction about domestic violence in the medical curriculum. To move forward, faculty must overcome their discomfort with the topic yet acknowledge that teaching about it is difficult and requires personal stamina and empathy with colleagues. Faculty must also agree to collaborate with those who have sensitivity and expertise in the area, and must make a long-term commitment to prepare physicians to recognize problems of domestic violence and work effectively with its victims and perpetrators. In Minnesota, training about interpersonal violence against women has been successfully incorporated into the curriculum of a family medicine residency program and the three medical schools. Residents in the community-oriented program learn to focus on domestic violence during patient examinations, as part of clinical activity, through provider networks, by working with other community groups, and as members of state or national organizations. This hierarchy was incorporated into a “matrix of community medicine” that describes appropriate activities at each level for each activity involved in providing community-oriented primary care (defining the population, assessing problems, intervening, monitoring, and building community partnerships). The resulting framework was used to describe the scope of potential involvement in domestic violence by the residency program. The matrix was also used to display the issues, resources, and programs available to train residents about domestic violence. The medical schools incorporate discussions of domestic violence in preclinical courses at all sites, allow students to work with abuse victims during clinical rotations, and offer a variety of extracurricular activities. This training is enhanced by using the community agencies and resources that represent years of experience in the field. The training is challenging because responding to cases of domestic violence is difficult and time consuming. Teachers must be able to move past their personal discomfort with the subject and approach the issue with stamina.