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Doctors' roles should be integrated with the needs of patients and society
The World Health Organization's study on domestic violence against women highlights the need for immediate action.1 The study across 10 countries used robust culturally appropriate methods to assess the extent and effects on health of intimate partner violence and non-partner violence in 24000 women. The lifetime prevalence of physical or sexual intimate partner violence (or both) in women who had ever had a partner ranged from 15% to 71% (29-62% at most sites), though prevalence varied significantly between and within countries (large cities versus less populated areas).
We know more about the epidemiology of this type of violence than how to identify, prevent, and reduce it. However, recent research has made great strides, including identifying optimal methods for further evaluation of case screening in emergency departments, family medicine practices, and women's health clinics2; examining women's acceptance of screening2 3; identifying effective interventions4; and identifying successful strategies for training and continuing medical education.5 Further research is still needed, though, especially to evaluate interventions6 and assess whether universal screening is effective.7
We can learn much from WHO's methodology and data collection methods, which relied, among other things, on partnerships with women's organisations and with other key stakeholders within each country. Of the 15 recommendations in the WHO report, two concern strengthening the health sector response (box 1) and take a clinical and public policy perspective, as others have done.8 The recommendations inform the basis for defining the competency of doctors when dealing with intimate partner violence. If the identified competencies reflect the needs of patients, and, as much as possible, broader needs of society, then we are a small step closer to implementing these two WHO recommendations.
The CanMEDS (Canadian medical education directives for specialists) framework on the competency of doctors, which was developed by the Royal College of Physicians and Surgeons of Canada, is currently used in several countries.9 It is intended for use by educators, teachers, trainees, practising doctors, researchers, and other health professionals (for example, for understanding how doctors work on teams). Although CanMEDS may not be completely transferable across specialties and jurisdictions or valid for non-specialists, it is useful to consider what constitutes competency when dealing with intimate partner violence.
CanMEDS recognises seven (overlapping) roles for doctors—medical expert (central role), communicator, collaborator, health advocate, manager, scholar, and professional (box 2). Each role has its own elements and key enabling competencies that have been described in detail elsewhere.9 Box 3 gives examples of how the CanMEDS roles can help direct doctors towards practising effectively when dealing with intimate partner violence.
While CanMEDS has been used here for illustrative purposes, other competency frameworks could also be used. The concept of developing doctors' competency in intimate partner violence is not new.10 To be valuable, these frameworks need to share the CanMEDS focus on what distinguishes doctors from other health professionals (medical expert) and on competencies that go beyond doctors' technical knowledge and skills to the needs and expectations that society places upon them.11 An open debate about what constitutes such competencies is needed to develop an international perspective and to guide training programmes and continuing medical education. We need to learn from educational leaders about their experiences and evaluations of providing training about intimate partner violence using learning goals matched to competencies. We also need to find effective ways to deal with the resistance that may come from adding this to medical school curriculums.12
We must recognise the difference between a doctor knowing and being able to perform a competency13 and actually implementing that competency in practice. Once we have international consensus on what constitutes such competency, the next step is to assess it in practice, and ultimately to use it to set standards and measure performance.
Finally, we must recognise that efforts to identify what constitutes competency of doctors in dealing with intimate partner violence must be considered in tandem with research, as evidence is still unavailable for many aspects of patient care (for example, universal screening versus diagnostic case-finding methods7). All this can only be achieved if doctors and society acknowledge the epidemic of intimate partner violence, recognise it as a global health and human rights issue, and devote resources to dealing with it.
Competing interests: None declared.
Provenance and peer review: Commissioned; not externally peer reviewed.