The Future of Family Violence Education: It is all about the money! Academy of Violence and Abuse Minneapolis, MN April 24, 2009 Richard D. Krugman, MD Vice Chancellor for Health Affairs and Dean, School of Medicine University of Colorado Denver

Sadly, I have no conflicts to disclose. Disclosures Sadly, I have no conflicts to disclose.

Objectives Understand the mechanics of curricular change in our institutions. Understand how supply and demand affect quality improvement in higher education.

Disclaimers The views expressed here are my own and may change dramatically at a moment’s notice. The experiences I have had are at a single School of Medicine and may or may not be replicable elsewhere.

A Brief History of Medical Education 19th Century Apprenticeship and Proprietary Schools 20th Century Flexner report. Curriculum is the responsibility of “the faculty”. Most schools have “Basic Sciences” and then “Clinical rotations” for two years each. Required courses are taught by departments. Many electives exist and are developed by individual faculty interested in a specific area.

Medical Education (con’t) In the latter part of the 20th Century, LCME requires “central management and control of the curriculum” by the Dean. Curricula begin to incrementally change. Some new schools of medicine find this process easier than older ones. Accreditation “shoulds and musts” drive some change, but these are usually additions (it is not easy to eliminate parts of the curriculum).

Meanwhile… In the latter third of the 20th century, child abuse and family violence become increasingly recognized within our society. The crescendo of calls to “include CA/N or FV in curricula begins (usually after a highly publicized fatality). By 2001, the failure to get the rightful place in curricula led to the IOM report: Confronting Chronic Neglect: The Education and Training of Health Professional on Family Violence.

Four Major Recommendations HHS: Create Family Violence Centers Model after Injury Control, Alzheimer’s etc. Educators: Address essential skills, teaching strategies that should be taught. Overcome “barriers”. Health systems (academic and others) should test new models of training/care. Feds should provide support and incentives for evaluating curricula.

What happened? not much!

Why Not Much? In the last eight years not much of substance has happened because: The report was issued 9/10/2001. The government was side tracked by other issues But mostly, there has been no flow of dollars to change how schools look at this issue.

Why Not Much? (con’t) The cornerstone of the recommendations – funding research and training centers – has not happened. The economic environment of most schools of medicine has softened – in the fiscal sense of the word – over the last eight years while attitudes of faculty have hardened.

Why Not Really? The field is not (and maybe should not) be lumped together. CA/N and Family Violence and Elder Abuse are now, and always have been, at very different stages of development. They are viewed as “social” problems and use coercive, legalized approaches. Although genetic and natural history studies may show more than an association among all three.

What About the Curriculum? Most curricula are now competency based. The odds of students getting through medical school without ever hearing about child abuse and/or family violence is small. The odds of students getting more than a lecture or two and some small group discussion on the topics in four years is smaller.

We are now implementing our 3rd year of the new curriculum with our first class doing the ist year of new clinical rotations

Phases I & II

Phases III & IV

So What About the Money? Most schools of medicine, and nearly all school of medicine faculty, are fiscalophilic: they grow towards money. The absence of funding streams for research and training means that Chairs and/or Deans will not invest in programs that focus on these areas because there will be little return on that investment.

University of Colorado Denver School of Medicine Trend in Sources of Revenue 1982 – 2008 estimated

Where Will the Money Come From? Research and Training NIH? HRSA? Foundations? Without it, no academic department will be very interested in supporting the area.

Conclusion Unless these fields are repackaged as health problems that are preventable and treatable, I suspect that little progress will be made over the next decade. Philanthropy for social issues is not as high a priority as it is for health problems. This group needs to have long lunches with geneticists, neuroscientists and pharmacologists interested in the biology of violent behavior.

Thank you for listening. (If you did)