“But he loves me. And I love him.” I stared at the leopard spot bruises littering her body. I was a psychiatry registrar and she was my patient, who was having a psychotic breakdown due to years of intimate partner violence (IPV).
I left psychiatry, but I never escaped it. I now work in the Department of Obstetrics and Gynaecology at the University of Cape Town as a medical officer and medical educationist (which is someone with particular expertise in health professions education). Intimate partner violence followed me too; the leopard that never changed its spots. Practically every week, it brought to light another woman’s story of abuse: Abuse that was hardly ever externally visible, yet had a marked impact on their health outcomes.
No one was talking about it. Colleagues avoided it. Students hid behind books. But those in the know saw it too.
One day, Dr Kate Joyner, a mental health nurse in the community, responsible for teaching family medicine registrars, came to alert us to the fact that the registrars were incapable of identifying IPV, much less managing it. She appealed to us to address this gap in our undergraduate curriculum.
My fire was stoked, and I volunteered to do a curriculum map of how and where IPV was taught in the UCT undergraduate Health Sciences curriculum, assisted by Professor Lorna Martin, Professor Lillian Artz and a then-student, Dr Theresia Rubler. The conclusion: Teaching on IPV existed, but it was patchy, not integrated and not practical. Students asked: “But what can I do?” IPV was not even addressed in my very own courses on women’s health.
That was my starting point. I found a space in my fifth-year gynaecology course. My workshops began in 2014. I focused on how to suspect and identify IPV, as well as how to practically manage such a situation. Feedback about the training was overwhelmingly positive and students asked that the training appear earlier in their curriculum. Since I also convene the third year women’s health course, as well as the sixth year obstetrics course, I built a mini-IPV curriculum, starting it in third year with the foundational work, outlining the extent of the problem and discussing how popular culture and patriarchal structures desensitise us all to violence, especially violence against women and minorities.
The workshop then addresses when to suspect IPV, how to ask about it and how to manage it. Importantly, IPV is framed as a healthcare issue rather than a legal one, because: 1. Victims are most likely to disclose to a healthcare practitioner; 2. IPV can impact just about any health matter you can think of; and 3. It costs the health sector billions of rands.
In the fifth year gynaecology course, we discuss real-life case studies. Two of these have been written by current or ex-UCT students, detailing their own personal experiences of IPV. In sixth year, we do one final top-up with another case study. In all cases, interactive learning and groupwork are used, with the underpinning pedagogical approach being Jack Mezirow’s theory of transformative learning.
I now also teach physiotherapy students as well as registrars in our department and others.
The workshops were the focus of my Sub-Saharan Africa-FAIMER Regional Institute (SAFRI) medical education fellowship: I interviewed key stakeholders at various NGOs helping survivors of IPV to ask them what they felt young doctors should know about IPV. This was a crucial project, because those closest to survivors could give them a voice, and make the teaching truly meaningful and relevant.
For a teaching intervention to be of any possible success, it is crucial to communicate its importance to students. This is more than standing in a classroom telling them how important this issue is. These workshops are duly performed (DP) requirements: A student cannot sit the exam if they did not attend. The material is also examinable. Thus, there is a clear message to students that this topic is valued in the curriculum.
But how does one know that one’s training is successful? It’s one thing to get good feedback after a workshop, but quite another to truly know whether one’s intervention is working. Who knew that social media would be able to answer the age-old question of whether young doctors are doing what one taught them to do at university? As it turns out, several ex-students have told me on social media about situations of IPV that they have identified and felt confident in managing.
Have there been any challenges? Of course. What I did not anticipate was the number of students who came to me after the workshops to confide in me about their own experiences of IPV. Some asked to be excused from the workshops so as not to relive traumas they had experienced, which I naturally allowed. The very worst was knowing that some of the perpetrators were in our very own student body. This has been incredibly difficult to navigate and has cost me personally.
Another major challenge is that very few doctors are taught about IPV at medical school, which creates another dilemma: My students are more knowledgeable and more skilled in the area of IPV than the vast majority of their other supervising doctors, and it can be a struggle when the decision-making person isn’t aware of, or is dismissive of something like IPV. How do students deal with that powerlessness? (They email me, but this is not enough, nor is it sustainable.)
Finally, while IPV teaching is integrated within my own ambit, it does need to continue to be represented in other disciplines so that students do not only think about this in gynaecological patients, or indeed only in women. IPV can present in any discipline and there needs to be more cross-disciplinary integration.
And so, we press on.
Because of all the interpersonal violence in SA, it is estimated that about two-thirds of this is intimate partner violence.
Because we have the highest intimate femicide rate in the world.
Because my students are some of the only students in the country getting this training, and who will ask, if not them? DM
"If you try to predict the future know that you will be wrong. The trick is to be as least wrong as possible; and be ready to change when you see how wrong you are!" ~ Sir Michael Howard