Bridge is published by the Boston University Office of University Relations.
dean sees family violence as critical health problem
Not long after Elaine Alpert was named assistant dean of student affairs
at BU's School of Medicine in 1987, a third-year student demanded to know
when MED was going to add a domestic violence course. Alpert asked him
to put his ideas in writing. Family violence was the province of social
workers and the police, she figured, not doctors.
A week later she was making rounds in a Boston hospital when a surgeon
asked her for advice on an antibiotic. "I asked him what the problem
was," Alpert recalls, "and he said, 'Oh, it's just some lady
who got beat up by her boyfriend and she has pneumonia under her rib fractures.
What drug do I use?' That's when I realized that we have a huge black
hole in medical education."
Since then Alpert has become an expert on family violence curricula and
a reformer whose message is catching on: medical schools must do a better
job training health-care practitioners to intervene on behalf of abuse
"We need to improve the way we teach physicians, the way we practice
what we teach, and the way we evaluate what we're doing," says Alpert,
an associate professor of medicine at MED and of public health at SPH.
Alpert has lectured on family violence intervention at medical schools
around the country and has written widely on the subject. She founded
and is the faculty advisor for the Boston University Domestic Violence
Advocacy Project, serves on the Massachusetts Governor's Commission on
Domestic Violence, and is a member of the Health and Public Policy Committee
of the American College of Physicians.
For several years Alpert has taught an SPH course on family violence in
collaboration with David Shannon, coordinator of victim recovery services
at Fenway Community Health in Boston. And for the past 18 months she served
on an Institute of Medicine (IOM) committee on domestic abuse education.
On September 10 the committee released a report to Congress recommending
ways that hospitals, medical schools, federal agencies, and professional
organizations can collaborate to improve the treatment of abuse victims
in medical settings.
The IOM project was the largest concerted effort to date to examine the
training of health-care practitioners in this field.
"There are some training programs around the country," Alpert
says, "but we still have a long way to go. Our students feel more
comfortable putting in a catheter and using all kinds of fancy technical
equipment than they do just sitting with a patient and asking questions
like, 'How are things at home? Have you been hit, hurt, or threatened?
Do you feel safe? You don't deserve this. Help is available.'"
Family violence affects as many as one in four children and adults in
the United States during their lifetimes, according to a conservative
estimate by the Centers for Disease Control and Prevention. The problem
knows no social or economic boundaries: in a study conducted five years
ago, 38 percent of entering students at three Massachusetts medical schools
reported having been physically, sexually, or emotionally abused as children
or having been the victims of intimate partner violence or sexual assault
Abuse victims turn up daily at HMO offices and hospital emergency rooms.
But signs of inflicted injury may be subtle. Many victims will complain
of chronic ailments such as back pain, headaches, or stomach problems
that don't have clear explanations. Others have sexually transmitted infections
or substance abuse problems, or keep missing appointments.
"It's not just people who come in beaten up and bruised," Alpert
says. "It's basically the entire gamut of primary care medicine.
Chronic medical and psychological problems are often the red-flag indicators
Physicians, nurses, and even dentists are in a unique position to blow
the whistle on abusers, Alpert says. Yet many health-care practitioners
either fail to see past the cover stories that victims tell about their
wounds, or lack the training to persuade patients to admit their problem
and seek help.
Often patients will deny they have been abused because they think the
physician will call their assailant, who is likely to become enraged and
even more dangerous, or they fear that a social worker will take their
"You need to be able to set some ground rules with the patient: who's
working for whom, and what are the limits of confidentiality in a medical
encounter," Alpert says.
Given the constraints of managed care, she adds, many physicians are simply
overwhelmed by their workload and feel they have no time to sit with patients
and ask questions. Even when an abuse victim is identified, many health-care
practitioners lack an established protocol for following up on the case.
"We need to work in close connection with community resources so
we have a seamless way of taking care of a victim's health," Alpert
says. "We will have to change the entire way medicine is taught,
organized, and practiced. It need not be a dramatic change, but a cultural
shift, so that we treat family violence as the very critical health problem
that it is."
To read the Institute of Medicine report, Confronting Chronic Neglect:
the Education and Training of Health Professionals on Family Violence,