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MED dean sees family violence as critical health problem

By Hope Green

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.

	Elaine Alpert speaks at a meeting of the American Medical Association Foundation in San Diego, where she received the organization's 1999 Health Education Award. Photo by Bill Marsh

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 victims.
"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 as adults.

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 of abuse."
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 children away.

"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, visit http://www.nap.edu/books/0309074312/html.

19 October 2001
Boston University
Office of University Relations