Personal view or opinion piece
Open Access

Intimate Partner Violence: Using Standardized Patients to Improve Trauma-Informed Care in the era of the Covid-19 Pandemic

Hedda Dyer[1], Desiree Stelly[1], Gretchen LeFever Watson[1]

Institution: 1. Ross University School of Medicine
Corresponding Author: Dr Hedda Dyer ([email protected])
Categories: Learning Outcomes/Competency, Students/Trainees, Clinical Skills, Simulation and Virtual Reality, Undergraduate/Graduate
Published Date: 27/04/2020

Abstract

Intimate partner violence (IPV) is a global public health problem that has been exacerbated by the social isolation measures currently in place in countries around the world. The authors appreciate the importance of teaching medical students the skill sets to cope with the recognition and diagnosis and medical management of IPV. This is because physicians are most often the first point of contact for victims of IPV. It is also essential to ensure medical students become self-aware of the emotional triggers which may be associated with caring for victims of IPV.  This opinion piece explains how medical educators can make a difference in training future physicians in caring for victims of IPV. With the current COVID-19 pandemic bringing the issue of IPV sharply into focus, this paper outlines why medical educators should ensure that medical students are equipped to deal with the societal consequences emanating from the COVID-19 pandemic which will reverberate into the future. Therefore, there is no more time to waste. We are facing a critical juncture, with the current cohort of medical students and physicians exposed to the disproportionately high levels of personal, professional, and emotional trauma that have resulted from the COVID-19 pandemic. Training is imperative; it is of paramount importance for our future medical professionals to be self-aware of their emotional triggers.

Keywords: Intimate Partner Violence; Domestic Violence; Medical Education; Medical students; Emotional Triggers; Covid-19; Pandemic; Standardized patients; Trauma informed care

Introduction

“I just never imagined that a 60-year-old woman could be a victim of domestic violence”, was the reason given during a debriefing meeting with a 2nd-year medical student who was unsuccessful at his Clinical exam. And the case scenario on that day was a female who had presented with the chief complaint of “I fell and hit my head,” but who, upon deeper probing was a victim of Intimate Partner Violence (IPV). Intimate partner violence (IPV) refers to abuse and aggression that occurs in a close relationship and is a global public health problem (World-Health-Organization, 2017). As a surgeon, nurse (RN), and clinical psychologist, we have each encountered patients who have suffered this form of trauma. Both in our clinical roles and as medical educators, we have observed how difficult it can be for many healthcare professionals to adequately appreciate why healthcare professionals should address this common societal problem within the context of a patient encounter. Contrary to common misconceptions, IPV is prevalent in every community and all levels of society, regardless of age, socio-economic status, sexual orientation, gender, race, religion, or nationality. Physical violence is associated with emotionally abusive and controlling behavior, both of which contribute to a systematic pattern of dominance and control. The “devastating consequences of domestic violence can cross generations and last a lifetime.” (National-Coalition-Against-Domestic-Violence, 2015).  IPV has recently been thrust into the international spotlight with the ongoing COVID-19 pandemic. The restriction on movement has caused a plethora of emotional crises for all age groups, genders, and socio-economic statuses.  The effect of ‘stay-at-home’ orders has meant that victims of IPV will be isolated with their abusers with little or no way of escape, access, or recourse to help outside the home (Lanier and Maume, 2009). During this current situation of social isolation, access to healthcare may be the only avenue of escape; a doctor or nurse would be one of the available strategies for victims to escape from the abuse (Riddell, Ford-Gilboe and Leipert, 2009). There is now an urgent call for action globally to address increased prevalence in IPV resulting from the social isolation measures in which governments around the globe have been enacted (Bocquet, 2020; Peterman et al., 2020).

Why does IPV matter to medical educators?

The health effects of IPV are wide-ranging, with a devastating impact on physical, sexual, reproductive, and mental health. IPV can lead to increased morbidity and even death. Thirty-five percent of women worldwide have experienced IPV, and 38 percent of murders committed against women globally are by their intimate partners (World-Health-Organization, 2017). Physicians are often the first point of contact for victims of IPV; however, physicians are usually not equipped or able to recognize the signs of IPV (Gotlib Conn et al., 2014).  In a small focus group study of Canadian orthopedic surgical residents, many felt unprepared and ill-equipped to interview suspected victims of IPV. They were also uncertain about how and where to refer these patients for help. Despite the high prevalence of IPV, not a single trainee reported learning about IPV during postgraduate training (Gotlib Conn et al., 2014). Research has also documented that 4th-year medical students feel uncomfortable caring for patients who present with signs and symptoms of IPV (Heron et al., 2010). There is a need for training of student physicians in recognizing and referring victims of IPV. Now is the opportune time for medical educators to leverage the current pandemic, wherein health care professionals, through their personal experiences of COVID-19 –related trauma, can now view trauma-informed care through the lens of the victim. This conversation is essential to the doctor-patient dyad (Beverly et al., 2018). Students must be prepared to address the impact of IPV on the physical, sexual, and mental health issues during and after the COVID-19 pandemic.

How can medical educators make a difference?

As medical school faculty members, and consistent with the published literature, the authors have observed how challenging it is for most medical students to effectively respond to standardized patients who present as victims of IPV. And yet, the Liaison Committee on Medical Education (LCME®) accreditation standards state “the faculty of a medical school ensure that the medical curriculum includes instruction in the diagnosis, prevention, appropriate reporting and treatment of the medical consequences of common societal problems.” (LCME® 2019). Since 2008, this standard has been explicitly tied to the need to address the medical consequences of common societal problems such as IPV. As medical educators, the authors have endeavored to meet the LCME IPV standard by using standardized patients to address the identified IPV training gap. Namely, they have incorporated IPV cases into the 2nd year medical school curriculum as part of the Advanced Interviewing Skills Training (AIST) program. Students’ AIST scores are based, in part, on their ability to recognize and address both the physical and psychological health effects of IPV. To raise awareness that IPV occurs in all iterations of intimate partnerships, the authors are currently piloting a same-sex IPV case. The call to action by the global healthcare community is even more urgent given the ‘new normal’ whereas, as educators, it is incumbent upon us to prepare our students to be self-aware of their own on-going traumatic experiences during the COVID-19 pandemic (Pfefferbaum and North, 2020), (Beverly et al., 2018). COVID-19 is the new trigger word and will be so for the foreseeable future. Therefore, as medical educators, we can help our students to prepare for the casualties of COVID- 19 from both a personal and professional perspective, thereby equipping them with the skills sets to practice trauma- informed care. 

Conclusion

With the alarming global IPV prevalence statistics, coupled with their socio-economic and generational impacts on individuals and society, medical educators must improve IPV training among the next generation of physicians. Before graduating from medical school, every physician should be capable of recognizing the signs and symptoms of IPV and skilled at discussing this topic with patients. For maximal results, IPV training ought to begin in undergraduate medical education, before students start their clinical rotations.

Take Home Messages

In our experience, medical students benefit from having an IPV standardized patient encounter as part of their clinical skills training. We believe that providing this critical component; the medical profession can help to combat the medical consequences of IPV. As has been highlighted by the current COVID-19 pandemic, the call for action is now.

Notes On Contributors

Dr. Hedda G. Dyer, MB CHB Ed, MRCS Ed, MBA is an Associate Professor in Department of Clinical Foundations, Director of the Semester 4X/05 Clinical Skills Course and Clinical Co- Module Director Gastrointestinal Modules at the Ross University School of Medicine, in Barbados. She is a  General Surgeon with a Special interest in Breast Surgical Oncology.

 

Ms. Desiree Stelly, MBA, MSN, RN, BSN, BS, CLNC is the Manager of the Standardized Patient Program within the Department of Clinical Foundations, at the Ross University School of Medicine, in Barbados. She is a Registered Nurse.

 

Dr. Gretchen B. LeFever Watson, PhD, is an Associate Professor in the Department of Clinical Foundations at the Ross University School of Medicine in Barbados. She is a Clinical Psychologist and a Consultant for organizational safety and change management.

Acknowledgements

None.

Bibliography/References

Beverly, E. A., Díaz, S., Kerr, A. M., Balbo, J. T., et al. (2018) 'Students' Perceptions of Trigger Warnings in Medical Education', Teach Learn Med, 30(1), pp. 5-14. https://doi.org/10.1080/10401334.2017.1330690

Bocquet, D. (2020) UN chief calls for domestic violence ‘ceasefire’ amid ‘horrifying global surge, UN News. Available at: https://news.un.org/en/story/2020/04/1061052 (Accessed: 07/04/2020).

Gotlib Conn, L., Young, A., Rotstein, O. D. and Schemitsch, E. (2014) '"I've never asked one question." Understanding the barriers among orthopedic surgery residents to screening female patients for intimate partner violence', Can J Surg, 57(6), pp. 371-8. https://doi.org/10.1503/cjs.000714

Heron, S. L., Hassani, D. M., Houry, D., Quest, T., et al. (2010) 'Standardized Patients to Teach Medical Students about Intimate Partner Violence', West J Emerg Med, 11(5), pp. 500-5. Available at: https://escholarship.org/uc/item/4gj125fz (Accessed: 07/04/2020).

Lanier, C. and Maume, M. O. (2009) 'Intimate partner violence and social isolation across the rural/urban divide', Violence Against Women, 15(11), pp. 1311-30. https://doi.org/10.1177/1077801209346711

LCME (2018) 'Functions and Structure of a Medical School - (contains the LCME Standards) 2019-2020'. Available at: www.lcme.org/publications/ (Accessed: 23/02/2020).

National-Coalition-Against-Domestic-Violence (2015) Domestic violence national statistics.  Available at: www.ncadv.org (Accessed: 23/02/2020).

Peterman, A., Potts, A., O’Donnell, M., Thompson, K., et al. (2020) 'Pandemics and Violence Against Women and Children', Center for Global Development, (CGD Working Paper 528).  Available at: www.cgdev.org (Accessed: 07/04/2020).

Pfefferbaum, B. and North, C. S. (2020) 'Mental Health and the Covid-19 Pandemic', N Engl J Med. https://doi.org/10.1056/NEJMp2008017

Riddell, T., Ford-Gilboe, M. and Leipert, B. (2009) 'Strategies used by rural women to stop, avoid, or escape from intimate partner violence', Health Care Women Int, 30(1-2), pp. 134-59. https://doi.org/10.1080/07399330802523774

World-Health-Organization (2017) Violence against women, (Newsroom-Fact Sheets) https://www.who.int/news-room/fact-sheets/detail/violence-against-women (Accessed: 23/02/2020).

Appendices

None.

Declarations

There are no conflicts of interest.
This has been published under Creative Commons "CC BY-SA 4.0" (https://creativecommons.org/licenses/by-sa/4.0/)

Ethics Statement

Ethics approval was not required as this is an opinion piece.

External Funding

This article has not had any External Funding

Reviews

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Ken Masters - (08/10/2020) Panel Member Icon
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An interesting paper on the very delicate issue Intimate Partner Violence, and using Standardized Patients to improve trauma-informed care in the era of the Covid-19 Pandemic.

The authors have succinctly laid out the issues and difficulties, especially under the current isolation, of IPV and teaching medical students about recognising and dealing with it. I would, however, like to see some issues addressed:

• “Contrary to common misconceptions, IPV is prevalent in every community and all levels of society, regardless of age, socio-economic status, sexual orientation, gender, race, religion, or nationality”. While this is true, the statement gives the impression that the prevalence is equal across all these demographic groups. It would, perhaps, be useful, to issue a qualifier, with a reference to a source that a reader could consult to see differences.

• I would like to see some expansion on the initial statistics: The statistics cited in the heading “Why does IPV matter to medical educators?” are a useful start, but do not complete the picture. Given that physicians are expected to treat people of all genders, and the authors have also noted that IPV occurs in all genders, it would be useful if the statistics of more than one gender could be given, otherwise there is a risk that readers will be alerted to the issue when dealing with one gender only.

• Based on the website cited, the percentage cited in this paper appears to be incorrect. The 35% cited includes “non-partner sexual violence”; the figure for IPV is 30%. (I understand that the difference is small, but, especially on such a sensitive topic, it is crucial that the authors are on point with their data).

• The title of the paper is a little misleading: The main part of the title is “Using Standardized Patients to Improve Trauma-Informed Care in the era of the Covid-19 Pandemic”. The reader would then expect that the paper is primarily about using standardized patients to improve trauma-informed care in the era of the Covid-19 Pandemic. Yet the description of the relevant project using standardized patients covers barely five lines of the paper (and it is not mentioned in either the Abstract or the Conclusion). I would recommend that either the project is given more space, or the article’s title is adjusted.

• A minor point: perhaps the authors could break their paragraphs up a little, so that the reader is not met with a rather imposing wall of text.

The project outlined does sound interesting. I look forward to seeing Version 2 of this paper in which further details are given, (and, perhaps later, a more detailed research study on the topic), so that readers may learn more on how to train students around this important topic.

Possible Conflict of Interest:

For transparency, I am an Associate Editor of MedEdPublish.

Joshua Francis - (11/05/2020)
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I have read and cogitated the article under review and hence; Violence by an intimate partner is linked to both immediate and long-term health, social, and economic consequences. Factors at all levels — individual, relationship, community, and societal — contribute to intimate partner violence. This type of violence should include emotional abuse even when partners are not physically isolated together..

Mention should have included prevention:

What about Preventing intimate partner violence which requires reaching a clear understanding of those factors, coordinating resources, and fostering and initiating change in individuals, families, and society.

Usual good job Dr. Dyer and her Team-keep up the good work-relelevant!
Possible Conflict of Interest:

Non

Mohamed Hany Shehata - (01/05/2020)
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I wonder if there is anything new that this article adds. Intimate partner's violance has always been part of students' training and will continue to be.I understand that it is one of multiple problems that will increase because of the current circumstances.
The term "standardized patient" simply is not accepted to me at least ethically.
Samar Ahmed - (28/04/2020)
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Thank you for raising this important point that is a rising issue post COVID pandemic. The manifestation of IPV has increased after the lock down and practitioners working in this field have felt this rise.
Raising a flag for this issue is really important and the tie between this and the role if medical educators is very important. A great addition to this work was to find an actual guide to support student learning about IPV in this paper. It was kind if frustrating to find no added value for educators who are interested in educating students on IPV. Hopefully more information can be added to sequel papers.
Trevor Gibbs - (28/04/2020) Panel Member Icon
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There is little doubt that the Covid-19 pandemic has caused us to look carefully not only on how we teach, how students learn and our assessment procedures, but it also has caused us to look into our curriculum and think about what is missing. The rise in domestic abuse has been a feature of many recent news items, linking it to the psychological effects of social distancing and quarantining procedures. So this paper has really come at a very important time, pointing out the deficiency of learning outcomes in intimate partner violence (IPV) ( I would include other forms of domestic abuse within this subject). It is a very well written paper that presents a good case for IPV within the curriculum. Of course, including a new subject into what for many is an over-crowded curriculum, means we have to think of what we substitute; that itself means we reflect on the content of our curricula too.
I think that this is a very insightful paper that should make curriculum developers consider their curricula, post Covid-19
Possible Conflict of Interest:

For transparency, I am one of the Associate Editors of MedEdPublish.