Intimate partner abuse: developing a framework for change in medical education

Addressing domestic violence presents unique challenges for individual physicians and for the institutions that shape medical education and practice. In addition to the need to acquire new knowledge and skills, clinicians must confront the feelings and social beliefs that shape their responses to patients, develop new frameworks for understanding complex social issues, and generate collaborative models for working in partnership with community groups. Educators, in turn, must provide training experiences that foster the development of those understandings and skills, institutional structures that support their integration into routine practice, and faculty who model nonabusive behaviors in all aspects of training and medical care. Expanding traditional medical paradigms to address the multiple dimensions of abuse can lay the groundwork for such a process. In addition, students need to be encouraged to develop awareness of the larger social forces that affect all of our lives and health, and to recognize their potential roles as community members in ending domestic violence. This article offers suggestions for changes in the structure of medical education as part of generating a health care system contribution to ending abuse in this society. Creating a model for fostering nonabusive relationships at individual and institutional levels within the health care system can provide a paradigm for transforming the conditions under which abuse is tolerated. Physicians' effectiveness with victims of domestic violence requires a model based on the principles of prevention, safety, empowerment, advocacy, accountability, and social change. The incorporation of these principles into clinical practice requires, in turn, a paradigm shift in the structure of medical education from biomedical models to a more comprehensive framework. Such a model would include recognition of the individual and societal forces that generate and sustain abuse, contextual factors that mediate women's experiences of abuse and shape their options, and individual and systemic factors that shape providers' responses. This perspective makes it easier to consider, for example, that psychiatric symptoms may actually be adaptive coping methods or survival strategies. Traditional medical teaching formats do not provide opportunities to address the attitudes and feelings that may affect a clinician's ability to provide appropriate care or to acquire the skills necessary for an optimal response. Role plays, faculty modeling, video and in-person observation, and simulated patients are useful tools for helping medical students learn to interact in ways that are not retraumatizing or disempowering to patients. Recognizing the potentially abusive aspects of medical training and creating environments that do not permit such behavior are important both to improving the health sector's response to domestic violence and creating a society that does not tolerate abuse. Informed by a broader perspective, medical students are less likely to accept the constraints of their practice environments and may join with others to bring about social change.