Education Columns

Sireesha Reddy, MD; Iris Price, MA; Lola Aguiniga, LCSW

Background
Every year, over 10 million women and men in the United States experience intimate partner violence (IPV) by a current or former partner, and approximately three million children witness IPV in their homes.^1,2 Family medicine physicians, given their continuity relationships with patients, have the unique opportunity to identify and link survivors of IPV to appropriate resources. Therefore, it is imperative that we train resident physicians to effectively screen for and provide resources to patients who report personal or familial experiences with IPV.

Studies report a majority of physicians do not screen their patients for IPV. ^3,4 However, the greatest predictor of providers routinely screening is having had prior training in IPV.⁵ A 2010 survey of family medicine residency program directors (PDs) found that IPV training is on the rise. PDs reported that their IPV training curriculum consisted primarily of clinical precepting, lectures, and case vignettes; 36% of the programs reported a domestic violence shelter experience for resident physicians, but specifics of the experience were not provided.⁶ Within the clinical setting, attempts to increase screening include a verbal adaptation of the written HITS (Hurts, Insults, Threatens harm, and Screams) screening tool and prompting in clinic using cue cards.^4,7 In response to the push to increase knowledge about and screening of IPV within the primary care setting, our program sought to provide a hybrid didactic-experiential learning experience as part of our behavioral and women’s health rotations.

Curriculum Overview
University of California, San Francisco-Fresno Family and Community Medicine is a model for community-based training, balancing resident education with patient care services for a multicultural and underserved population, spread across both urban and rural areas. In developing our IPV curriculum, we chose to partner with the Marjaree Mason Center (MMC), Fresno County's only dedicated domestic violence center, which has provided shelter and support services to approximately 5,600 women and children annually since 1979. The experience was funded by the Song Brown Program and was part of the curriculum from 2014 to 2017. We are currently seeking additional funding sources so that we can continue to both provide patient care and offer this training to our resident physicians.

The required hybrid experience consisted of didactic lectures and an onsite rotation at MMC, where residents spent one afternoon per week for a 4-week block. Residents also had required reading and completed a suspicious injury report on a fictional case. This report is required by California penal code for physical abuse not against children or the elderly, or sexual assault of adults or children. At the MMC, residents led interactive health-related educational sessions on topics such as mental health, health care maintenance, nutrition, and parenting, followed by an open Q&A.

After the educational session, the clinic opened for the remainder of the afternoon, and the residents provided basic medical services. The shelter gave us a room that was converted into our walk-in clinic. Through this service-learning experience, we sought to increase knowledge of IPV and the comfort level of our resident physicians when serving survivors and their families while providing outpatient services and resources. The continuity clinic site for the residency is one mile from the shelter. If further testing or a higher level of care was necessary, appointments could be made with the same resident who treated the survivors, allowing for continuity of care.

Impact
Resident physicians’ change in knowledge and comfort level related to IPV were assessed through pre/postrotation questionnaires. Of the 39 residents who completed the hybrid experience, paired sample t-tests showed a significant increase in comfort level with providing medical services, discussing social situations, discussing abuse-related injuries, notifying law enforcement for women and children, and discussing IPV resources (P<0.001). Knowledge about IPV increased significantly (P<0.001), especially for acknowledging survivors can make appropriate choices regarding their relationships and social situations. Our findings suggest that our hybrid IPV curriculum was an effective method for educating residents about IPV and increasing their comfort level working with survivors of IPV.

Conclusion
Before the implementation of our IPV curriculum, our resident physicians lacked knowledge and comfort in providing care to people experiencing IPV. Our hybrid curriculum increased their knowledge and comfort level providing care to this patient population, suggesting the effectiveness of our intervention. While it is difficult to ascertain whether this improvement is attributable to the clinic experience, didactics, or a combination of the two, the comfort level survey did contain items that were addressed only in the clinical setting (eg, discussing abuse-related injuries, social situations, and relationships with the patients, and specifics regarding the provision medical services). Multiple studies have supported the notion that physicians who receive any education about IPV are more likely to screen their patients, and that experiential learning is the most effective intervention. Our outcomes support this research. Residency programs should consider incorporating IPV training into their curriculum because acquiring skills to effectively identify and provide resources to survivors of IPV is important to ensuring that our patients receive high-quality, comprehensive, and necessary care.
References

1. Breiding MJ, Basile KC, Smith SG, Black MC, Mahendra RR. Intimate Partner Violence Surveillance: Uniform Definitions and Recommended Data Elements, Version 2.0. Atlanta, GA: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention; 2015.
2. Stiles MM. Witnessing domestic violence: the effect on children. Am Fam Physician. 2002;66(11):2052-2067.
3. Parsons LH, Zaccaro D, Wells B, Stovall TG. Methods of and attitudes toward screening obstetrics and gynecology patients for domestic violence. Am J Obstet Gynecol. 1995;173(2):381-386. https://doi.org/10.1016/0002-9378(95)90256-2
4. Knight R, Remington PI. Training internal medicine residents to screen for domestic violence. Womens Health Gend Based Med. Volume 9, Number 2, 2000;9(2):167-74.
5. Lapidus G, Cooke MB, Gelven E, Sherman K, Duncan M, Banco L. A statewide survey of domestic violence screening behaviors among pediatricians and family physicians. Arch Pediatr Adolesc Med. 2002;156(4):332-336. https://doi.org/10.1001/archpedi.156.4.332
6. Cronholm PF, Singh V, Fogarty CT, Ambuel B. Trends in violence education in family medicine residency curricula. Fam Med. 2014;46(8):620-625.
7. Shakil A, Bardwell J, Sherin K, Sinacore JM, Zitter R, Kindratt TB. Development of verbal HITS for intimate partner violence screening in family medicine. Fam Med. 2014;46(3):180-185.