Sonia Dosanjh

Challenges to the practice of evidence-based medicine during residents' surgical training: a qualitative study using grounded theory.

Purpose. To examine surgical trainees’ barriers to implementing and adopting evidence-based medicine (EBM) in the day-to-day care of surgical patients. Method. In 2000, 28 surgical residents from various subspecialties at a hospital affiliated with McMaster University Faculty of Health Sciences in Ontario, Canada, participated in a focus group (n = 8) and semistructured interviews (n = 20) to explore their perceptions of barriers to the practice of EBM during their training. Additional themes were explored, such as definitions of EBM and potential strategies to implement EBM during training. The canons and procedures of the grounded theory approach to qualitative research guided the coding and content analysis of the data derived from the focus group and semistructured interviews. Results. Residents identified personal barriers, staff-surgeon barriers, and institutional barriers that limited their ability to apply EBM in their daily activities. Residents perceived their lack of education in EBM, time constraints, lack of priority, and fear of staff disapproval as major challenges to practicing EBM. Moreover, the lack of ready access to surgical EBM resource materials proved to be an important additional factor limiting EBM surgical practice. Residents identified several strategies to overcome these barriers to EBM, including hiring staff surgeons with EBM training, offering coursework in critical appraisal for all staff, improving interdepartmental communication, and providing greater flexibility for EBM training. Conclusions. Surgical residents identified a general lack of education, time constraints, lack of priority, and staff disapproval as important factors limiting incorporation of EBM. Curriculum reform and surgeon education may help overcome these barriers.

(Mis)Perceptions About Intimate Partner Violence in Women Presenting for Orthopaedic Care: A Survey of Canadian Orthopaedic Surgeons

BACKGROUND Domestic violence is the most common cause of nonfatal injury to women in North America. In a review of 144 such injuries, the second most common manifestation of intimate partner violence was musculoskeletal injuries (28%). The American Academy of Orthopaedic Surgeons is explicit that orthopaedic surgeons should play a role in the screening and appropriate identification of victims. We aimed to identify the perceptions, attitudes, and knowledge of Canadian orthopaedic surgeons with regard to intimate partner violence. METHODS We surveyed members of the Canadian Orthopaedic Association to identify attitudes toward intimate partner violence. With use of a systematic random sample, 362 surgeons were mailed questionnaires. The questionnaire consisted of three sections: (1) the general attitude of the orthopaedic surgeon toward intimate partner violence, (2) the attitude of the orthopaedic surgeon toward victims and batterers, and (3) the clinical relevance of intimate partner violence in orthopaedic surgery. Up to three follow-up mailings were performed to enhance response rates. RESULTS A total of 186 orthopaedic surgeons responded (a response rate of 51%), and 167 (91%) of them were men. Most orthopaedic surgeons (95%) estimated that <10% of their patients were victims of intimate partner violence, and most respondents (80%) believed that it was exceedingly rare (a prevalence of <1%). The concept of mandatory screening for intimate partner violence was met with uncertainty by 116 surgeons (64%). Misconceptions were perpetuated by surgeons who believed that inquiring about intimate partner violence was an invasion of the victims privacy, that investigating intimate partner violence was not part of their duty, that victims choose to be a victim, and that victims play a proactive role in causing their abuse. By the completion of the survey, the majority of surgeons (91%) believed that knowledge about intimate partner violence was relevant to their surgical practice. CONCLUSIONS Discomfort with the issue and lack of education have led to misconceptions among Canadian orthopaedic surgeons about intimate partner violence. The relevance of intimate partner violence to surgical practice is well understood, but studies regarding its prevalence are needed as a first step to change the current paradigm in orthopaedic surgery.

The Prevalence of Intimate Partner Violence across Orthopaedic Fracture Clinics in Ontario

BACKGROUND from 1999 to 2004, an estimated 653,000 women in Canada were either physically or sexually abused by their current or previous intimate partners. We aimed to determine the proportion of women presenting to orthopaedic fracture clinics for the treatment of musculoskeletal injuries who had experienced intimate partner violence, defined as physical, sexual, or emotional abuse, within the past twelve months. METHODS we completed a cross-sectional study of 282 injured women attending two Level-I trauma centers in Canada. Female patients presenting to the orthopaedic fracture clinics anonymously completed two previously developed self-reported written questionnaires, the Woman Abuse Screening Tool (WAST) and the Partner Violence Screen (PVS), to determine the prevalence of intimate partner violence. The questionnaire also contained questions that pertain to the participants demographic characteristics, fracture characteristics, and experiences with health-care utilization. RESULTS the overall prevalence of intimate partner violence (emotional, physical, and sexual abuse) within the last twelve months was 32% (95% confidence interval, 26.4% to 37.2%). Twenty-four (8.5%) of the injured women disclosed a history of physical abuse in the past year. Seven women indicated that the cause for their current visit was directly related to physical abuse. Ethnicity, socioeconomic status, and injury patterns were not associated with abuse. Of the twenty-four women who reported physical abuse, only four had been asked about intimate partner violence by a physician; none of these physicians were the treating orthopaedic surgeons. CONCLUSIONS our study suggests a high prevalence of intimate partner violence among female patients with injuries who presented to two orthopaedic fracture clinics in Ontario. Surgeons and health-care personnel in fracture clinics should consider intimate partner violence when interacting with injured women.

Perceptions of Intimate Partner Violence: a cross sectional survey of surgical residents and medical students

Abstract: Background: Intimate partner violence (IPV) is an important health issue. Many medical students and residents have received training relating to IPV, but previous studies show that many students feel that their training has been inadequate. Our objective was to assess the knowledge, attitudes and perceptions about IPV among university medical students and surgical residents. Methods: We administered an online survey to a sample of Ontario medical students and surgical residents. The survey instrument was a modified version of the Provider Survey. Results: Two hundred medical students and surgical residents participated in the survey (response rate: 29%). Misperceptions about IPV among respondents included the following: 1) victims must get something from the abusive relationships (18.2%), 2) physicians should not interfere with a couple’s conflicts (21%), 3) asking about IPV risks offending patients (45%), 4) Victims choose to be victims (11.1%), 5) it usually takes ‘two to tango’ (18.3%), and 6) some patients’ personalities cause them to be abused (41.1%). The majority of respondents (75.0%) believed identifying IPV was very relevant to clinical practice. The majority of medical students (91.2%) and surgical residents (96.9%) estimated the IPV prevalence in their intended practice to be 10% or less. Most of the medical students (84%) and surgical residents (60%) felt that their level of training on IPV was inadequate and over three quarters of respondents (77.2%) expressed a desire to receive additional education and training on IPV. Conclusions: There are misconceptions among Canadian medical students and surgical residents about intimate partner violence. These misconceptions may stem from lack of education and personal discomfort with the issue or from other factors such as gender. Curricula in medical schools and surgical training programs should appropriately emphasize educational opportunities in the area of IPV.

Orthopaedic Surgeons’ Knowledge and Misconceptions in the Identification of Intimate Partner Violence Against Women

BackgroundIntimate partner violence (IPV)—physical, sexual, psychologic, or financial abuse between intimate partners—is the most common cause of nonfatal injury to women in North America. As many IPV-related injuries are musculoskeletal, orthopaedic surgeons are well positioned to identify and assist these patients. However, data are lacking regarding surgeons’ knowledge of the prevalence of IPV in orthopaedic practices, surgeons’ screening and management methods, and surgeons’ perceptions about IPV.Questions/purposesWe aimed to identify (1) surgeon attitudes and beliefs regarding victims of IPV and batterers and (2) perceptions of surgeons regarding their role in identifying and assisting victims of IPV.MethodsWe surveyed 690 surgeon members of the Orthopaedic Trauma Association. The survey had three sections: (1) general perception of orthopaedic surgeons regarding IPV; (2) perceptions of orthopaedic surgeons regarding victims and batterers; and (3) orthopaedic relevance of IPV. One hundred fifty-three surgeons responded (22%).ResultsRespondents manifested key misconceptions: (1) victims must be getting something out of the abusive relationships (16%); (2) some women have personalities that cause the abuse (20%); and (3) the battering would stop if the batterer quit abusing alcohol (40%). In the past year, approximately ½ the respondents (51%) acknowledged identifying a victim of IPV; however, only 4% of respondents currently screen injured female patients for IPV. Surgeons expressed concerns regarding lack of knowledge in the management of abused women (30%).ConclusionOrthopaedic surgeons had several misconceptions about victims of IPV and batterers. Targeted educational programs on IPV are needed for surgeons routinely caring for injured women.

Intimate partner violence and musculoskeletal injury: bridging the knowledge gap in orthopaedic fracture clinics.

Intimate partner violence (IPV) is a serious health issue. There have been widespread research efforts in the area of IPV over the past several decades, primarily focusing on obstetrics, emergency medicine, and primary care settings. Until recently there has been a paucity of research focusing on IPV in surgery, and thus a resultant knowledge gap. Renewed interest in the underlying risk of IPV among women with musculoskeletal injuries has fueled several important studies to determine the nature and scope of this issue in orthopaedic surgery. Our review summarizes the evidence from surgical research in the field of IPV and provides recommendations for developing and evaluating an IPV identification and support program and opportunities for future research.

Screening for Intimate Partner Violence in Orthopedic Patients: A Comparison of Three Screening Tools

Accurately identifying victims of intimate partner violence (IPV) can be a challenge for clinicians and clinical researchers. Multiple instruments have been developed and validated to identify IPV in patients presenting to health care practitioners, including the Woman Abuse Screening Tool (WAST) and the Partner Violence Screen (PVS). The purpose of the current study is to determine if female patients attending an outpatient orthopaedic fracture clinic who screen positive for IPV using three direct questions (direct questioning) also screen positive on the WAST and PVS. We conducted a prevalence study at two Level I trauma centres to determine the prevalence of IPV in female patients presenting to orthopaedic fracture clinics for treatment of injuries. We used three methods to determine the prevalence of IPV; 1) direct questioning, 2) WAST, and 3) PVS. We compared the prevalence rates across the three screening tools. Ninety-four women screened positive for IPV using any method. The prevalence of IPV was 30.5% when a direct questioning approach was utilized, 12.4% using the WAST, and 9.2% using the PVS. The WAST identified 37.2% (35/94) of the IPV victims detected and the PVS identified 27.7% (53/94) of the IPV victims detected, whereas direct questioning identified 89.4% of the IPV victims. Identification of IPV may be under-estimated by the WAST and PVS screening tools. Our findings suggest direct questioning may increase the frequency of disclosure of IPV among women attending outpatient orthopaedic clinics.

Child Protection Involvement and Victims of Intimate Partner Violence Is There a Bias

Several studies have explored the disproportionate number of children of color involved in child protective services, raising concerns that racial bias in the system results in more women of color being referred to child protection. The authors conducted a case series to analyze whether a womans race and ethnicity influenced referrals to child protective services in a domestic violence context. Data were obtained through interview records of 263 women (38% women of color) at a Minneapolis-based advocacy and therapy organization. The findings suggest that women who face multiple forms of oppressions may have greater risk of being involved with child protection services.