Are Future Doctors Taught to Respond to Intimate Partner Violence? A Study of Australian Medical Schools

Abstract

Intimate partner violence (IPV) is a leading cause of morbidity and mortality among women of childbearing age. This study aimed to describe delivery of IPV education in Australian pre-vocational medical degrees, and barriers and facilitators influencing this delivery. Eighteen Australian medical schools offering pre-vocational medical degrees were identified. Two were excluded as they had not finalized new curricula. One declined to participate. At least one staff member from each of the remaining 15 schools completed a telephone survey. Main outcome measures included whether IPV education was delivered within the degree, at what stage, and whether it was compulsory; mode and number of hours of delivery; and barriers and facilitators to delivery. Twelve of the medical schools delivered IPV education (median time spent per course = 2 hr). IPV content was typically included as part of Obstetrics and Gynecology or General Practice curriculum. Barriers included time constraints and lack of faculty commitment, resources, and funding. The two schools that successfully implemented a comprehensive IPV curriculum used an integrated, advocacy-based approach, with careful forward planning. Most Australian pre-vocational medical students receive little or no IPV education. The need remains for a more consistent, comprehensive approach to IPV education in medical degrees.

Keywords

intimate partner violence domestic violence medical training doctor training curriculum

Intimate partner violence (IPV) is a leading cause of morbidity and mortality among women of childbearing age (World Health Organization, 2013a), with an estimated prevalence of 1 in 10 women (Hegarty, 2006). IPV is defined as, “behaviour by an intimate partner that causes physical, sexual or psychological harm, including acts of physical aggression, sexual coercion, psychological abuse and controlling behaviours” (World Health Organization, 2013b, p.vii). It has been found to pose an even greater health risk to women than raised blood pressure, tobacco use, and body weight (Vos et al., 2006), and frequently contributes to a range of common health complaints, including depression, anxiety, chronic pain, post-traumatic stress disorder, gynecologic, and general health issues (Campbell, 2002; Hegarty, Gunn, Chondros, & Small, 2004; Rees et al., 2011; World Health Organization, 2013b). Doctors may be the first or only point of contact for women exposed to IPV, as women may be reluctant or unable to seek alternative sources of assistance (Ansara & Hindin, 2010; Feder et al., 2011).

Consequently, best-practice guidelines encourage doctors to identify and respond to IPV as part of routine patient care (Joint Commission for the Accreditation of Healthcare Organizations, 2011; National Institute for Health and Care Excellence, 2014; Royal Australian College of General Practitioners, 2008; Taft, Hegarty, & Feder, 2006; World Health Organization, 2013b). However, there is a large gap between these best-practice guidelines and actual medical practitioner behavior. Doctors are often reluctant to inquire about IPV, and women tend not to disclose abuse to doctors without specific inquiry (Hegarty, Feder, & Ramsay, 2006). As a result, only a minority of women exposed to IPV are recognized and treated in health care settings (Hegarty & Taft, 2001).

Insufficient practitioner education and training in IPV may contribute to this gap. Prior research has found that IPV training of medical students is often delivered in an inconsistent or ad hoc manner, if at all (Frank et al., 2006; Wathen et al., 2009). In a 1992 study, only 70% of medical schools in Australia delivered any IPV education and, of those that did, the maximum education provided was 3 hr (Lawrence, 1992). This is concerning, given training in IPV can improve clinical practice in this area (Connor, Nouer, Mackey, Banet, & Tipton, 2012; Lo Fo Wong, Wester, Mol, & Lagro-Janssen, 2006). Given many medical schools in Australia and internationally have recently undergone comprehensive curriculum review (Australian Medical Council, 2012), and a number of new Australian medical schools have been established, one might expect an improvement in IPV education delivery. This study therefore aims to describe current IPV education delivered to Australian, pre-vocational medical students, and barriers and facilitators influencing this delivery.

Method

A systematic search of all Australian universities identified a total of 18 medical schools offering pre-vocational medical degree courses in Australia (one of these medical schools was collaboratively administered by two separate universities). Two universities were excluded as the full curriculum of their new graduate-entry, pre-vocational degree had not yet been finalized.

Within the remaining 16 medical schools, the member of staff most familiar with the relevant curriculum content was identified via the school’s Medical Education Unit contact list. Once permission had been established via email, a copy of the survey and a consent form were sent to this staff member and a time arranged for telephone completion of the survey. The study was approved by the University of Melbourne Human Research Ethics Committee.

The telephone survey was semi-structured and took between 20 and 45 min to complete. Respondents were asked whether IPV was delivered in the undergraduate medical degree (including both informal delivery, for example, embedded in other topics, and formal delivery). If yes, they were asked about the nature of this education, including number of hours, mode of delivery, stage/s of training, topics included, whether it was compulsory, and who it was delivered by. Those who did not deliver IPV education were asked whether it might be introduced in the future, what barriers discouraged introduction of IPV education, and how these barriers might be overcome. All respondents were asked to select and elaborate on factors that influenced their medical school’s delivery of IPV education, including barriers and facilitators. They were also asked to identify any other departments likely to deliver IPV education, so that a relevant staff member could be interviewed.

Responses were documented verbatim by the interviewer. In the two instances where more than one survey was completed per medical school, results of the surveys were combined to form one overall response for that school (there were no major discrepancies between responses).

Descriptive statistics for demographic data and quantitative responses to closed questions were generated in SPSS (the nature and size of the study meant that it was inappropriate to generate any inferential statistics using the data). Qualitative responses to open-ended questions were analyzed by authors J.V. and K.A., using thematic analysis (Patton, 2002). Both of these authors had prior training and experience in qualitative research, including thematic analysis; author J.V. also had prior expertise in educational program development theory and practice, and author K.A. was a medical registrar. Findings from studies on IPV education conducted in other countries and in previous decades helped guide identification of themes in the data (e.g., Frank et al., 2006; Lawrence, 1992; Wathen et al., 2009), along with literature discussing barriers and facilitators to this education (e.g., Warshaw, 1997). New themes were also identified through inductive identification of emerging themes. Each response was then coded to one of more of these themes.

Results

Fifteen out of the 16 eligible medical schools responded to the survey (93.8%), with one school declining to participate. The length of pre-vocational medical degrees offered by eligible medical schools ranged from 4 to 6 years, with a mean of 5 years. Twelve of the faculty members from eligible medical schools who completed the telephone survey were female and 5 were male. One respondent was an associate dean, 1 was a head of department, 4 were professors, 3 associate professors, 3 senior lecturers, 3 lecturers, and 2 were curriculum development managers/officers.

IPV Education, Content, and Delivery

Of the 15 respondents, 12 delivered IPV education in some form, whereas 3 did not. In each of these 12 cases, at least some of the IPV content was compulsory, although 2 respondents expressed concerns about whether this compulsory participation was actually enforced.

Of the schools that delivered IPV education, seven presented this curriculum in the final years of the course, five in the intermediate years, and three in the first two years. Two of the latter schools presented specific IPV content at more than one stage in the course.

Among the medical schools that delivered IPV-related content, the majority (n = 10) spent approximately 1 to 3 contact hours on IPV education across the duration of the course, with a median of 2 hr. The two most comprehensive IPV programs were delivered for 10 to 14 hr across the duration of the course.

Where IPV content was delivered, it was typically included as part of the Obstetrics and Gynecology curriculum (n = 5) or General Practice curriculum (n = 4). Other units in which IPV was taught included Society and Health, Human Development, Behavioral Science, Law and Ethics, Rural Health and Indigenous Health, sometimes in combination with other topics such as child abuse. Six of the medical schools also reported incorporating IPV education into problem-based learning experiences or clinical cases.

The way in which IPV content was delivered also varied. Of the schools that provided IPV training, 9 presented information in a lecture or as part of a lecture, 4 as workshops, 4 as a nuance in problem/case-based teaching, and 2 as online modules (several universities educated students using multiple methods).

For the most part (n = 10), IPV content was delivered by a member of staff available at the university, including psychologists, general practitioners, and other academics with a special interest in IPV. Three of the medical programs used an external member of the community, which included special presentations from community IPV agencies or a social worker employed at the university’s affiliated teaching hospital.

Table 1 summarizes the material covered during IPV education. Interestingly, only 4 out of the 12 schools used a framework, model, or theory to guide their IPV education. The majority of medical schools covered risk factors and correlates that may lead to IPV, identification of IPV, and community resources available. Most of the universities also covered responding to IPV, characteristics of those experiencing or perpetrating IPV, and issues relevant to multicultural communities. Topics less frequently presented included issues specific to gender, indigenous relationships, and same-sex relationships.

Table 1.

Intimate Partner Violence Topics Covered (N = 12 Medical Schools).

Topics Covered	n (%)
General overview of IPV against women	12 (100.0)
Local community resources	11 (91.7)
IPV risk factors or correlates	11 (91.7)
Identification of IPV	11 (91.7)
Responding to IPV (e.g., interventions)	10 (83.3)
Characteristics of IPV victims and perpetrators	9 (75.0)
Issues specific to multicultural communities	9 (75.0)
Issues specific to gender	8 (66.7)
Issues specific to indigenous communities	7 (58.3)
IPV in same-sex relationships	6 (50.0)
Utilization of a model, framework, or theory to guide IPV education	4 (33.3)
IPV by women against men	4 (33.3)
Common couple violence (i.e., abuse by both partners against one another)	3 (25.0)

Note. IPV = intimate partner violence.

IPV Education Barriers and Facilitators

Thirteen of the total 15 respondents reported time constraints as a barrier to IPV education delivery, especially with regard to competing content demands.

Such a condensed program and a lot of competing voices as to what is a must know, a need to know and what can be picked up by experience. (University 14)

This included all three schools that did not deliver IPV education.

Domestic violence is not essential when it comes into competition with more essential topics, for example if it came up against what depression looks like. (University 8)

[IPV education] is challenging to introduce at expense of other different content. . . . It would be lovely to teach everything, but we’re not able to fit it all in a four year course. (University 15)

Insufficient access to instructors (n = 10), resources (n = 6), and funding (n = 3) were also reported as barriers to IPV education delivery.

[We] make best use of available staff that can squish it into 10 minutes. (University 16)

[Instructors’] clinical load takes priority. Every attempt is made to take the session . . . but it’s done on ad hoc. (University 14)

Money has to stretch so far from central budget. (University 6)

For five respondents, these barriers were further compounded by lack of faculty/department commitment to IPV education. However, other respondents reported faculty/department commitment as a positive influence (n = 3).

Yes, it is included because the faculty curriculum expects it to be included. (University 2)

Likewise, five respondents reported that opportunities for curriculum renewal had a negative influence on IPV delivery, whereas four reported a positive influence. The latter included one medical school which did not currently deliver IPV education but which may do in the future.

Currently doing curriculum mapping which could lead to some redevelopment [including IPV education]. (University 6)

Five respondents reported that student receptiveness influenced IPV education delivery, with some concerned about the ability of young students to take IPV education on board.

Influenced by their age, and some, I think they might be reluctant to delve too deeply into a social problem that might be hard to quantify. (University 6)

One of these respondents described how the school had now changed delivery of IPV education to enhance student receptiveness:

Initially the lecture and tute was very much focused on a public health approach . . . students were not so interested . . . So now it’s been changed so that the tute gives domestic violence case studies within clinical contexts and students work in groups. . . . Students are much more interested in learning and relating to domestic violence and find it more relevant with this format. (University 2)

Discussion

This study showed that 80% of Australian pre-vocational medical degrees included some form of IPV education, however, the extent and quality of this education was highly variable. The median time dedicated to IPV education in these degrees was 2 hr. Only a few of the medical schools took a comprehensive, multi-stage, multi-mode approach to delivery; the others took more of an ad hoc approach. Thus, at the time of this study, a sizable proportion of Australian medical students were denied adequate basic training in IPV recognition and response, consistent with prior research in Australia and other Western countries (Frank et al., 2006; Lawrence, 1992; Wathen et al., 2009).

One might expect IPV to be given the same curricula priority as issues sharing a similar disease burden, including raised blood pressure and tobacco use (Vos et al., 2006). But instead, IPV had been squeezed out of the curriculum where time constraints produced competing demands. Participant responses indicated this may have been due to lack of understanding of IPV’s role as an important medical issue (Freedy, Monnier, & Shaw, 2001). This is consistent with prior research on reasons for medical school resistance to IPV education (deLahunta & Tulsky, 1998). Without this understanding, future practitioners are not adequately equipped to treat mental health, gynecological, and chronic pain issues in situations where IPV is an underlying cause (Campbell, 2002; Hegarty et al., 2004; Rees et al., 2011). They may also be less inclined to seek out IPV education in later clinical training or practice. This low priority given to IPV education in most medical schools could also be viewed as yet another way in which institutional systems mirror and perpetuate community attitudes to IPV (Warshaw, 1997). When medical schools give very little time or attention to IPV education, they inadvertently communicate that IPV is not an important or prevalent issue.

Warshaw (1997) suggested that an advocacy-based approach to medical education can help address this lack of time and priority given to IPV education. This approach recognizes the psychosocial context in which a patient’s symptoms occur, and views the practitioner as facilitating change rather than directing it (Warshaw, 1997). Key principles promoted by Warshaw include basing IPV education on models of IPV, which take into account both the social construction and clinical context of abuse; creating a supportive learning environment conducive to IPV education; integrating both knowledge and skills needed in addressing IPV; preventing retraumatization of the patient and dealing with possible vicarious traumatization of the clinician; and, woven throughout each of these, the modeling of respectful relationships. A medical school that models healthy, respectful relationships with, and between, its staff and students will better equip future practitioners to model healthy, respectful relationships with their patients, which will in turn help facilitate empowerment and healing for those who have experienced IPV (Warshaw, 1997).

This paradigm allows IPV to be revisited at increasing complexity throughout the curriculum, as an essential part of understanding patient symptoms, rather than as a burdensome add-on. Strategies used in this approach include use of survivors’ stories and voices, direct modeling and role-playing (e.g., regarding ways to ask about and respond to IPV), and indirect modeling of constructive communication styles in the way faculty interact with students and each other (see Hegarty, O’Doherty, Gunn, Pierce, & Taft, 2008, for further practical examples). The supportive, collaborative learning environment necessary for an advocacy-based approach can also provide a safe space for the dialogue, self-reflection, and practice students need when learning about sensitive topics such as IPV.

The two medical schools in this study, which delivered 10 or more hours of IPV education successfully, used aspects of this advocacy-based approach. Deliberate, coordinated planning of explicit learning experiences focusing on IPV was an important feature of these degrees. This planning was informed by evidence-based models of IPV identification and intervention, and included specific attention to the knowledge and skill-sets needed, as well as to supporting students in this learning. Consistent with guidelines and research on effective IPV education, this learning was in a variety of formats (e.g., didactic, experiential, problem based, and community based), across multiple levels and areas of the curriculum (Buranosky, Hess, McNeil, Aiken, & Chang, 2012; Hill, 2005; Warshaw, 1997).

This approach to IPV education did not happen in isolation. Rather, it was embedded in, and reflective of, a broader medical school ethos and structure conducive to equipping practitioners with the skills and attitudes essential in addressing IPV. Both of these medical schools had built their medical curriculum around patient-centered models that emphasized treatment of the “whole-person” within each individual’s social context. Both used problem-based and case-based learning as part of this patient-centered approach. Patient-centered models facilitate IPV education by encouraging practitioners to look beyond the symptoms alone, to attend to possible underlying causes, and the patient’s overall context (Warshaw, 1997). They also promote critical thinking and evaluation of a range of possible responses, as opposed to one “correct” response. This may help emerging practitioners feel more confident and comfortable raising and addressing IPV with patients, without feeling they must know how to “fix” the situation (Warshaw, 1997). This patient-centered approach was also facilitated by a 12-month, small-town, placement compulsory in one of the degrees, giving students the opportunity to develop long-term practitioner–patient relationships.

Another key aspect of both of these medical school programs was an integrated curriculum. A well-planned integrated curriculum provides an ideal framework in which to present IPV as a complex issue requiring a sophisticated, multi-faceted approach (Warshaw, 1997). This integrated approach mirrors the integrated approach best taken to identifying and responding to IPV. Rather than becoming an extra thing the practitioner must remember to do, or the medical school must squeeze in to teach, it becomes an integrated part of looking at the whole picture when working with patients (Warshaw, 1997). An integrated curriculum also promotes an inter-disciplinary approach to medical practice, which is essential for providing inter-disciplinary support to patients experiencing IPV. As part of this integrated approach, specific IPV education was revisited at multiple year levels throughout the medical degrees provided by these two schools. This approach has been found to be essential for long-term implementation of learning, both generally and in the context of IPV education (Warshaw, 1997). It also mirrors the long-term approach needed in addressing IPV experienced by patients. As was the case for these two medical schools, it is essential that strategically planned opportunities for IPV knowledge and skill-set development be embedded when using an integrated approach. IPV education became easily lost in other degrees that used integrated and/or problem-based learning without this deliberate planning.

One of the two medical schools that offered the most comprehensive IPV curriculum also had clear systems for student support embedded into their medical program, with a specific, well-regarded staff member responsible for coordinating these systems. These systems included peer support and mentorship, as well as availability of confidential student counseling services. Students were encouraged to make use of these support mechanisms if they experienced any distress as a result of IPV-related content, as well as more generally throughout the course. This approach is not only important in modeling supportive environments but also in helping make students less vulnerable to vicarious trauma, both now and in future practice (Warshaw, 1997). Conversely, medical education systems that promote feelings of disempowerment and emotional detachment make students more vulnerable to vicarious trauma (Warshaw, 1997).

It is interesting to note that both of these medical schools were relatively new schools that had been established within the last decade. Both had developed their curricula around models that emphasize social context, community engagement, and professional ethics, and had identified IPV as an essential part of this holistic approach. This meant that IPV education had strong institutional support, not just as a particular topic area, but as an integral part of understanding a patient’s medical context. The pedagogical approaches taken by these schools further ensured IPV education was embedded in the curriculum, overcoming many of the time constraint and other barriers identified by other medical schools.

One limitation of the current study is that it was descriptive only, providing a broad overview of the current situation for delivery of IPV education to pre-vocation medical students in Australia. Collecting data from students was beyond the scope of the study, and so it was not possible to assess how the type and amount of IPV education provided affected on student knowledge, attitudes, and skills in dealing with IPV. Nor was it within the scope of this study to capture student perspectives on how and when IPV education should be delivered, and what they see as barriers and facilitators to learning in this area. Nonetheless, the information provided by faculty members who participated in this study gives valuable insight into how IPV education is being treated in curriculum planning. Further research could focus on medical student experiences of and perspectives on pre-vocational IPV educations, and relationships between type and intensity of this education, and clinical skills and attitudes in later practice. Subsequent uptake and outcomes of IPV education in post-professional and specialist programs also require further research.

In conclusion, over the past two decades, universities in Australia have made only small, inconsistent gains in preparing pre-vocational medical students for the IPV they will encounter in their work. This is consistent with international concerns raised about inadequate IPV training of medical practitioners (Frank et al., 2006; Wathen et al., 2009; World Health Organization, 2013b). A more consistent and comprehensive approach to IPV education is needed to ensure medical practitioners are equipped to recognize and respond to this prevalent cause of morbidity and mortality among women (Hegarty, 2006; Vos et al., 2006). Those medical schools that did offer quality IPV education showed that this is achievable even within the constraints of shorter medical degrees, through careful planning within an advocacy-based, integrated approach. It is imperative that IPV be given the priority it deserves alongside other prevailing health risks addressed in training Australia’s future medical practitioners.

Footnotes

Acknowledgements

The researchers would also like to sincerely thank all of the participating medical school faculty members who gave their time to contribute to this research.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was supported in part by a General Practice Students Network (Australia) academic scholarship awarded to author Karina Aprico.

Author Biographies

Jodie Valpied is a researcher in the Department of General Practice at The University of Melbourne specializing in researching sensitive issues, specifically intimate partner violence. She has a background in psychology and education, including curriculum development; holds a master of education degree; and is currently also completing a PhD in psychology.

Karina Aprico is an MBBS graduate from The University of Melbourne. She also holds a BSc (Hons) and PhD. As part of her MBBS studies, she completed the general practice student network scholarship program and a research collaboration with the Department of General Practice at The University of Melbourne.

Janita Clewett holds a bachelor of arts majoring in sociology and linguistics. She has worked in health and primary care research at The University of Melbourne and also in the federal government sector.

Kelsey Hegarty is an academic general practitioner who currently works as a professor in the Department of General Practice at The University of Melbourne and leads an Abuse and Violence in primary care research program. Her research includes complex interventions around identification of family violence in primary care and responding to women and children exposed to abuse.

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