Violence Prevention Education An Immersion Experience in the Community Medicine Clerkship Suzanne Harrison, MD Michael Muszynski, MD FSU College of Medicine

Objectives Recognize the gap between knowledge about domestic violence and recognition of abuse in the patient care setting Describe curriculum and outline project Outline preliminary survey data (knowledge & attitudes) – initial CDCS collection will not be complete until spring (behavior) Share student experiences Share challenges encountered

The Gap A gap often exists in medical school education regarding violence prevention education Most students have limited knowledge of domestic violence This restricts the students’ ability to recognize the impact of violence on a patient Decreased recognition limits integration of knowledge into patient care during clinical years How do we translate knowledge and attitudes into a change in behavior that improves recognition of violence in the patient care setting?

Curriculum Students introduced to screening tools during 1st year Doctoring course Dedicated 2 hour session during 2nd year Medicine & Behavior course Additional information provided during other sessions in Medicine & Behavior Required content during OB/Gyn Clerkship Optional exposure through student interest groups

Background Information Regional Campuses: Students distributed to 6 Regional Campuses across Florida during the 3rd and 4th years of medical school CDCS: Patient encounters are entered into the Clinical Data Collection System during required clinical experiences Community Medicine Clerkship: Required 3rd year clerkship during which students spent 3 weeks assigned to a community agency Emergency Medicine Clerkship: Required 4th year clerkship, 4 weeks

Project Overview Goals: Student Groups: To increase student exposure to survivors of domestic and sexual violence Measure knowledge, attitudes and behaviors related to domestic violence to see if greater exposure translates to increased comfort with and improved recognition of domestic violence in patient care Student Groups: Students placed in domestic violence shelters near each of our 6 regional campuses Students placed in other community agencies for the community medicine clerkship

The Student Experience The Clerkship begins with a half-day orientation on domestic and sexual violence, including first-hand question and answer sessions with survivors of domestic violence In a 3-week immersion experience, students are placed in a shelter for victims of domestic violence where they participate in social, medical and legal interventions Assigned readings for students Reflective papers are written at the end of each week, and the end of the Clerkship

Student Groups Study Group: Control group: Question: Selected students participate in the shelter immersion experience with additional training in sexual and domestic abuse Control group: Students participate in various community medicine experiences including but not limited to home health, hospice, health department, healthy start Question: Does the immersion experience have an effect on medical student recognition of violence in patient care?

Measurement Knowledge and attitudes about domestic violence are assessed with a survey instrument before and after the Community Medicine Clerkship Behaviors related to recognition of violence are measured by student documentation in CDCS during the 4th year required Emergency Medicine Clerkship Abuse, sexual Abuse/neglect, child Abuse/neglect, elder Domestic violence Domestic violence screening (listed as a procedure)

Survey Participation 96 students enrolled in initial study group (class of 2010) 89 students (92%) participated in pre-participation survey 68 students (71%) participated in post-participation survey, or 76% of initial participants 100% of students (8) placed in domestic violence shelter completed first survey, but only 80% (6) completed second survey

% students replying YES Survey Comparison Do you feel confident in your ability to identify the forms of domestic violence? % students replying YES

Survey Comparison How comfortable do you feel providing information resources to a patient following a disclosure of domestic violence? Pre Post

Survey Comparison How comfortable do you feel asking about domestic violence when a patient comes in with a suspicious injury? Pre Post

Survey Comparison How comfortable do you feel screening for domestic violence in a routine healthcare encounter? Pre Post

Recognition of Abuse & Neglect Not all students in initial group have completed 4th year required Emergency Medicine Clerkship First analysis of CDCS documentation of patient encounters will occur early summer following graduation when all student data is available

Student Experiences “…made me realize that it is just as important to ask women about emotional abuse as it is to inquire about physical abuse …shared this story with my classmates …I hope they will also take emotional (abuse) seriously when they encounter it as physicians.” “Though I had worked on Domestic Violence research in the past and was relatively familiar with patients in this situation, I could not come close to understanding the far-reaching effects of DV. After my first short week of the clerkship I will still not claim that I can understand what these patients go through but can say with certainty that the concept has become more real and tangible than ever.”

Student Experiences “She told of things that I can’t even imagine … children that witnessed this … my heart just broke for her and her children. Also, as strange as it sounds, I also hurt for the abusers because most of them become abusers due to past abuse that was inflicted on them. “…in many of the cases the abusers were not big, powerful and aggressive men…the women were even bigger in size in about 50% of the cases…helped me to realize that it’s definitely not a size issue but truly power and control predominantly of the mind.”

Challenges & Biases Student experiences varied, contact with survivors sometimes limited by shelter staff Coordination with residential shelters Appropriate training Low numbers of students in DV shelter Students self-selected for experience Short time frame using same survey Student participation dropped off for second survey Students may not “code” for all diagnoses when caring for a patient in the Emergency Department

Lessons Learned Local coordination and training may become imperative so shelters have confidence and allow for a meaningful student experience 3 weeks may not be long enough for students to complete training and work with survivors and advocates in the residential shelter environment

Community-Based Curriculum Domestic Violence education is typically presented in didactic or small group learning experiences This project takes the student out of the classroom and places them directly with the survivors and those who provide services, allowing the student to learn the system and provide services at an early stage in their medical career It will foster community partnerships and allow the student to observe how important this coordination of care will be for the continuity of patient care in later years

Implications for Others Domestic Violence education is extremely important for the training of future physicians, particularly primary care physicians who provide the majority of continuity of care This project allows students to interact directly with survivors of domestic and sexual abuse, learning from the patients and understanding the systems approach in an environment to which they might not otherwise be exposed Immersion in a shelter for a brief time is possible in other community medicine rotations, whether in medical school or residency

Will be uploaded to FMDRL Contact Information Investigators: Suzanne Leonard Harrison, MD suzanne.harrison@med.fsu.edu Michael Muszynski, MD michael.myszynski@med.fsu.edu Will be uploaded to FMDRL http://www.fmdrl.org/