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BMJ. 2007 April 7; 334(7596): 706–707.
PMCID: PMC1847868

Intimate partner violence

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 24 000 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.

Box 1 Recommendations from the WHO study1 aimed at strengthening the health sector response

Develop a comprehensive health sector response to the effects of violence against women

  • Identify roles for health professionals in advocating for prevention of violence and in providing services to women
  • Coordinate and work with other health professionals and with other sectors that care for abused women (for example, by creating formal referral processes and protocols)
  • Integrate appropriate non-stigmatising, non-blaming, respectful, secure, and confidential responses to violence against women into:
    • All aspects of care (such as emergency services, reproductive health services, mental health services, HIV related services)
    • Sensitising and training of health professionals

Use reproductive health services as entry points for identifying and supporting women in abusive relationships, and for delivering referral or support services

  • Sensitise and train reproductive health providers to recognise and respond appropriately to violence by having protocols to deal with it, using referral systems (if such systems are unavailable, providing information about legal and counselling options), ensuring confidentiality, and making women's safety a priority
  • Add an anti-violence component to antenatal services, parenting classes, and other services that involve men

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.

Box 2 CanMEDS definitions of doctors' roles. Reprinted with permission from appendix B of the CanMEDS 2005 physician competency framework9

Medical expert (the central role)

  • As Medical experts, physicians integrate all of the CanMEDS roles, applying medical knowledge, clinical skills, and professional attitudes in their provision of patient-centered care

Communicator

  • As Communicators, physicians effectively facilitate the doctor-patient relationship and the dynamic exchanges that occur before, during, and after the medical encounter

Collaborator

  • As Collaborators, physicians effectively work within a healthcare team to achieve optimal patient care

Manager

  • As Managers, physicians are integral participants in healthcare organizations, organizing sustainable practices, making decisions about allocating resources, and contributing to the effectiveness of the healthcare system

Health advocate

  • As Health advocates, physicians responsibly use their expertise and influence to advance the health and well-being of individual patients, communities, and populations

Scholar

  • As Scholars, physicians demonstrate a lifelong commitment to reflective learning, as well as the creation, dissemination, application and translation of medical knowledge

Professional

  • As Professionals, physicians are committed to the health and well-being of individuals and society through ethical practice, profession-led regulation, and high personal standards of behaviour

Box 3 Key features of the health sector WHO recommendations,1 with examples of CanMEDS roles9 in dealing with intimate partner violence

Integrating appropriate responses to violence against women into all aspects of clinical care

Medical expert
  • Apply best practice to identify, intervene, and refer cases of intimate partner violence

Professional
  • Deliver ethical, humane and compassionate care, recognising that blame may be cast, which may cause secondary adverse effects. Recognise limitations in expertise (and seek consultation if necessary)

Communicator
  • Facilitate patient centred therapeutic communication, including active empathic listening to establish trust. Work therapeutically with victims of intimate partner violence and share decision making

Manager
  • Participate in health systems for collaborative decision making and quality improvement. Victims of intimate partner violence need health services; doctors must manage and improve the effectiveness of their individual provider and overall programme within healthcare systems

Scholar
  • Identify and apply evidence based intimate partner violence screening and interventions, identify knowledge or practice gaps and model these competencies for others

Advocating for prevention and for services

Health advocate and medical expert
  • Use medical expertise and influence to improve the overall health of patients and populations. Identify and apply health determinants (social, cultural, economic) and strategies to promote health and prevent disease. Doctors must know how to help victims of intimate partner violence in navigating local systems and obtaining appropriate resources

Working with other health professionals and other sectors

Collaborator
  • Work effectively and appropriately within health and non-health sectors to facilitate coordinated intimate partner violence responses for individual patients and populations

Sensitising and training health professionals

Scholar
  • Educate patients and other providers about intimate partner violence; engage in lifelong learning through critical appraisal of evidence and evidence based practice

Professional
  • Serve as a role model; commit to appropriately 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.

Notes

Competing interests: None declared.

Provenance and peer review: Commissioned; not externally peer reviewed.

References

1. Garcia-Moreno C, Jansen H, Ellsberg M, Heise L, Watts C. WHO multi-country study on women's health and domestic violence against women. Initial results on prevalence, health outcomes and women's responses. Geneva: WHO. www.who.int/gender/violence/who_multicountry_study/en/index.html
2. MacMillan HL, Wathen CN, Jamieson E, Boyle M, McNutt L, Worster A, et al; for the McMaster Violence Against Women Research Group. Approaches to screening for intimate partner violence in health care settings. JAMA 2006;296:530-6. [PubMed]
3. Bair-Merrit MH, Feudtner C, Mollen CJ, Winters S, Blackstone M, Fein JA. Screening for intimate partner violence using an audiotape questionnaire: a randomized clinical trial in a pediatric emergency department. Arch Pediatr Adolesc Med 2006;160:311-6. [PubMed]
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8. Ahmed AM. Domestic violence as a public health problem. Sudanese J Public Health 2006;1:226-9.
9. Frank JR, ed. The CanMEDS 2005 physician competency framework. Better standards. Better physicians. Better care. Ottawa: The Royal College of Physicians and Surgeons of Canada. 2005. http://rcpsc.medical.org/canmeds
10. Alpert EJ, Sege RD, Bradshaw YS. Interpersonal violence and the education of physicians. Acad Med 1997;72:S41-50. [PubMed]
11. Frank JR, Langer B. Collaboration, communication, management and advocacy: teaching surgeons new skills through the CanMEDS project. World J Surg 2003;27:972-8. [PubMed]
12. Freedy JR, Monnier J, Shaw DL. Putting a comprehensive violence curriculum on the fast track. Acad Med 2001;76:348-50. [PubMed]
13. Miller GE. The assessment of clinical skills/competence/performance. Acad Med 1990;65:63-7. [PubMed]

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