Achieving safety and integrity in conducting research with intimate partner violence survivors.

In their paper, Burge et al. (see record 2014-23812-001) describe an innovative methodology for studying real-time antecedents to intimate partner violence (IPV), as well as the methods employed to ensure the safety of research participants. Over a 12-week timespan, 200 women in moderately violent relationships were asked to make daily phone calls, using a password-protected, interactive voice response system, to provide information about new violence and abuse, and the circumstances that surrounded it. The article details the many safety procedures employed. The authors report that only 2 women were withdrawn from the study for safety reasons. In addition, in post-participation interviews, many participants reported on the increased safety they experienced as a result of participating in the study. These results are discussed in the commentary as part of a growing trend that shows that studies that have well-designed safety procedures in place may actually constitute a kind of inadvertent but effective intervention for abuse survivors in healthcare settings. Implications of such procedures for continued research development in this area, as well as for designing and evaluating innovative health care-based IPV interventions are discussed.

Trends in violence education in family medicine residency curricula.

BACKGROUND AND OBJECTIVES: Violence is a significant public health issue with far-reaching implications for the health of individuals and their communities. Our objective was to describe trends in violence-related training in family medicine residency programs since the last national survey was conducted in 1997. METHODS: Surveys were sent to 337 US family medicine residency programs with the program director having active Society of Teachers of Family Medicine (STFM) membership. Measures included residency setting and characteristics, violence-related curricular content, teaching techniques and personnel, timing of content, and impact of changes in Residency Review Committee (RRC) and Accreditation Council for Graduate Medical Education (ACGME) requirements. Descriptive statistics and bivariate analyses comparing measures across time were used. RESULTS: A total of 201 (60%) surveys were completed. The most common violence curricula was child (83%) and elder abuse (76%), and the most common teachers of violence-related content were family physicians, psychologists, and social workers. The most common teaching methods were clinical precepting (94%), lectures (90%), case vignettes (71%), and intimate partner violence (IPV) shelter experiences (67%). ACGME and RRC changes were not reflected in self-reported measures of curricular emphasis or time. CONCLUSIONS: Violence curricular content and number of hours has been constant in family medicine residencies over time. An increase in the reported use of active learning strategies was identified as a trend across surveys. Next steps for violence curricula involve assessment of residents' competency to identify and intervene in violence.

Cultural adaptation of patient and observational outcome measures: a methodological example using the COMFORT behavioral rating scale.

BACKGROUND: There is little empirical evidence regarding the translation and cultural adaptation of self-report and observational outcome measures. Studies that evaluate and further develop existing practices are needed. OBJECTIVES: This study explores the use of cognitive interviews in the translation and cultural adaptation of observational measures, using the COMFORT behavioral scale as an example, and demonstrates a structured approach to the analysis of data from cognitive interviews. The COMFORT behavioral scale is developed for assessment of distress and pain in a pediatric intensive care setting. DESIGN: Qualitative, descriptive methodological study. SETTING: One general public hospital trust in southern Norway. PARTICIPANTS: N=12. Eight nurses, three physicians and one nurse assistant, from different wards and with experience caring for children. METHODS: We translated the COMFORT behavior scale into Norwegian before conducting individual cognitive interviews. Participants first read and then used the translated version of the COMFORT behavioral scale to assess pain based on a 3-min film vignette depicting an infant in pain/distress. Two cognitive interview techniques were applied: Thinking Aloud (TA) during the assessment and Verbal Probing (VP) afterwards. In TA the participant verbalized his/her thought process while completing the COMFORT behavioral scale. During VP the participant responded to specific questions related to understanding of the measure, information recall and the decision process. We audio recorded, transcribed and analyzed interviews using a structured qualitative method (cross-case analysis based on predefined categories and development of a results matrix). RESULTS: Our analysis revealed two categories of problems: (1) Scale problems, warranting a change in the wording of the scale, including (a) translation errors, (b) content not understood as intended, and (c) differences between the original COMFORT scale and the revised COMFORT behavioral scale; and (2) Rater-context problems caused by (a) unfamiliarity with the scale, (b) lack of knowledge and experience, and (c) assessments based on a film vignette. CONCLUSIONS: Cognitive interviews revealed problems with both the translated and the original versions of the scale and suggested solutions that enhanced the validity of both versions. Cognitive interviews might be seen as a complement to current published best practices for translation and cultural adaptation.

Involving the health care system in domestic violence: what women want.

PURPOSE Domestic violence is prevalent among women using primary health care services in Lebanon and has a negative effect on their health, yet physicians are not inquiring about it. In this study, we explored the attitudes of these women regarding involving the health care system in domestic violence management. METHODS We undertook a qualitative focus group study. Health care professionals in 6 primary health care centers routinely screened women for domestic violence using the HITS (Hurt, Insult, Threaten, Scream) instrument. At each center, 12 women who were screened (regardless of the result) were recruited to participate in a focus group discussion. RESULTS Most of the 72 women encouraged involvement of the health care system in the management of domestic violence and considered it to be a "socially accepted way to break the silence." Women expected health care professionals to have an "active conscience"; to be open minded, ready to listen, and unhurried; and to respect confidentiality. Additionally, they recommended mass media and community awareness campaigns focusing on family relationships to address domestic violence. CONCLUSIONS Addressing domestic violence through the health care system, if done properly, may be socially acceptable and nonoffensive even to women living in conservative societies such as Lebanon. The women in this study described characteristics of health professionals that would be conducive to screening and that could be extrapolated to the health care of immigrant Arab women.

Implementing radical curriculum change in a family medicine residency: the majors and masteries program.

BACKGROUND AND OBJECTIVES: There have been dramatic changes in the specialty of family medicine and the American health care system in the more than 40 years since the formation of the specialty. As a result, there is urgent need for experimentation and innovation in residency training to better prepare family physicians. METHODS: Waukesha Family Medicine Residency used a strategic planning process to identify four guiding concepts for a new model of residency education: intentional diversification; options for advanced training in a fourth year of residency; longitudinal, competency-based training; and strong fundamental background in family medicine skills. These concepts guided radical restructuring of the curriculum. RESULTS: The new Majors and Masteries curriculum begins with 19 months of training in core family medicine skills. Residents then elect to pursue a Major or Mastery in an area of interest. Majors are completed within 3 years, while Masteries are completed in 4 years and include advanced training (MPH, MBA, advanced obstetrics). Since implementation, residents have selected a broad range of Majors, three residents have elected advanced training in three different mastery areas, and resident recruitment has not been disrupted. CONCLUSIONS: The Majors and Masteries curriculum and the process used to implement it may benefit other residencies considering radical curriculum change.

Intimate partner violence.

Intimate partner violence is a common source of physical, psychological, and emotional morbidity. In the United States, approximately 1.5 million women and 834,700 men annually are raped and/or physically assaulted by an intimate partner. Women are more likely than men to be injured, sexually assaulted, or murdered by an intimate partner. Studies suggest that one in four women is at lifetime risk. Physicians can use therapeutic relationships with patients to identify intimate partner violence, make brief office interventions, offer continuity of care, and refer them for subspecialty and community-based evaluation, treatment, and advocacy. Primary care physicians are ideally positioned to work from a preventive framework and address at-risk behaviors. Strategies for identifying intimate partner violence include asking relevant questions in patient histories, screening during periodic health examinations, and case finding in patients with suggestive signs or symptoms. Discussion needs to occur confidentially. Physicians should be aware of increased child abuse risk and negative effects on children's health observed in families with intimate partner violence. Physicians also should be familiar with local and national resources available to these patients.

The development and evaluation of community health competencies for family medicine.

BACKGROUND: There is an increasing emphasis on teaching community-responsive care and population health in medical education. This focus requires a multidimensional perspective on community health that examines the determinants, ranges, and variations of health status and disease in the community as a whole. DESCRIPTION: The Department of Family and Community Medicine at the Medical College of Wisconsin sought to strengthen the community health curriculum in its residency programs by developing a core set of competencies in community health as well as a service-learning model to teach residents about community needs and strengths. EVALUATION: A common core curriculum was developed and evaluated based on these competencies. CONCLUSION: Residents who have mastered these competencies will be capable of functioning more effectively as community-responsive physicians.

Outcomes from a national multispecialty palliative care curriculum development project.

BACKGROUND: In 1998 we completed a successful regional pilot project in palliative care curriculum development among 32 internal medicine residency programs recruited from the mid-western United States. Between 1999 and 2004 this project was expanded to include 358 U.S. programs, from four specialties, based on new training requirements in internal medicine, family medicine, neurology, and general surgery. OBJECTIVE: To assess the 1-year outcomes from residency programs participating in a national multispecialty palliative care curriculum development project. MEASUREMENT: Outcome data obtained from residency programs' responses to a structured progress report 12 months after enrolling in the project and from published residency project reports. RESULTS: Three hundred fifty-eight residency programs, representing 27% of all eligible training programs in the four specialties, participated in the project. Outcome data was available from 224 residencies (63%). Most programs started new teaching in pain, non-pain symptom management, and communication skills. More than 50% of programs integrated palliative care topics within established institutional grand rounds, morbidity/mortality conferences or morning report. More than 70% of internal medicine and family practice programs began new direct patient care training opportunities utilizing hospital-based palliative care or hospice programs. New faculty development initiatives and use of quality improvement projects to drive curriculum change were reported in less than 50% of programs. CONCLUSIONS: Focused short-term instruction in palliative care curriculum development, in a diverse group of residency programs, is feasible and associated with significant curriculum change.

End-of-life care education in internal medicine residency programs: an interinstitutional study.

BACKGROUND: Integrating end-of-life care (EOL) education into medical residency programs requires knowledge of what programs currently teach and what residents learn. OBJECTIVE: Evaluate EOL teaching content and practices in internal medicine residency programs and the EOL knowledge of their faculty and residents. DESIGN: An interinstitutional pilot study. We examined patterns of EOL education, discerned from program directors' responses to structured surveys of institutional teaching and evaluation practices, and EOL knowledge, derived from the performance of faculty and residents on a 36-item knowledge examination. SUBJECTS: Program directors, faculty, and residents at 32 accredited U.S. internal medicine residency programs. RESULTS: Although all programs cited inclusion of some EOL education, expected EOL domains were not systematically taught or assessed. Pain assessment and treatment training was required in only 60% of programs. Even fewer programs required instruction on nonpain symptoms (<30%) or hospice and nonhospital care settings (22%). EOL assessment depends primarily on faculty's general ratings of residents' global competency; few programs use knowledge examinations or structured skill assessments. Directors identified barriers and support for improving education. On the knowledge examination, the mean score of residents increased across training levels (F = 21.7, p < .001), and the mean score of faculty was higher than residents' (57.6%: 48.9%, t = 51.6, p < .001). CONCLUSIONS: Existing internal medicine residency education lacks training in critical EOL care domains. Residency programs need additional training for residents and teaching faculty in EOL content and skills, with assessment practices that demonstrate competencies have been acquired. Program directors perceive institutional support for making these changes.

End-of-life curriculum reform: outcomes and impact in a follow-up study of internal medicine residency programs.

BACKGROUND: In 1998 we initiated a pilot project to evaluate the feasibility of recruiting and training internal medicine residency programs in methods designed to enhance and integrate end-of-life (EOL) instruction and assessment into their curriculum. OBJECTIVE: To evaluate participants' assessment of the training program and the 12-month impact of the training on the 32 residency programs' EOL teaching. DESIGN: Prospective multi-institutional study. MEASUREMENT AND RESULTS: After participating in training, all participants agreed/strongly agreed that the skills-related objectives of the training were met. Mean ratings of intention to continue with the program were consistent across trainees representing different academic ranks (F = 2.8, p = 0.07), levels of experience in EOL education (F = 1.3, p = 0.28), and involvement in other national EOL training programs (F = 1.5, p = 0.23). Twelve months after training, most programs (78%) continued with the project and had initiated EOL curriculum reform in seven key EOL domains.). CONCLUSIONS: The study suggests that focused training in EOL teaching methods and institutional change strategies can facilitate EOL curriculum reform.