Incorporating the Experiences of Youth with Traumatic Injury into the Training of Health Professionals

Introduction 

In the United States, youth are disproportionately represented among victims of violent injuries and, although significant progress has been made, there remains a great need to further reduce the frequency and burden of violence-related injury.1, 2 According to the Institute of Medicine, “…there is a yawning gap between what we already know about preventing and ameliorating injuries and what is being done in our communities, workplaces and clinics…education is the area in which the field of injury has made the least progress…”3 This lack of breadth and depth in education can be seen in the training of medical and public health practitioners. In fact, recent findings suggest that physicians are inadequately prepared to counsel families in youth violence.4

Efforts to reduce and prevent violence-related injury should therefore include training of medical and public health practitioners.5 Because health professionals are often primary contacts of youth involved in violence (as victims and as perpetrators), it is important that they be trained to provide adequate, appropriate services and referrals. Despite recommendations by numerous professional organizations to enhance healthcare professionals’ roles in youth violence prevention efforts, there has been little documentation on effective training methodology.6

To address this gap, the University of California, San Diego Department of Pediatrics (UCSD) partnered with Sharp HealthCare’s Institute for Injury & Violence Prevention to engage youth disabled by violence to teach medical students about opportunities for direct intervention in the lives of victims and perpetrators. Sharp HealthCare’s Think First San Diego violence prevention model, Sharp On Survival (SOS), includes live testimonials from young people who have sustained traumatic and preventable brain or spinal cord injuries as a result of making poor choices. These Voices for Injury and Violence Prevention (VIPs) participated in training fourth year medical students at UCSD in injury and violence prevention. They were part of a panel of health professionals, law enforcement, social service agencies, and victims of violence facilitating a workshop that highlighted violence as a public health problem and a physician’s responsibility in youth violence prevention. This article describes the background of the SOS program, the development of the medical students’ training in partnership with UCSD, and the impact of the VIP’s presentation on the students.

Background 

Community Pediatrics, a Division of the Department of Pediatrics at UCSD School of Medicine and a recipient of an Academic Center of Excellence in Youth Violence Prevention (UCSD ACE) from the CDC, is a multidisciplinary research group of pediatricians, psychologists, nutritionists, physical education specialists, health educators, biostatisticians, nurse practitioners, and social scientists with demonstrated experience designing and implementing culturally competent programs targeting underserved and at-risk populations. The UCSD ACE is committed to empowering communities to address and prevent youth violence by aligning the research, education, and outreach activities of the university with the needs of schools and community-based organizations. To this end, UCSD ACE creates and implements community response plans to youth violence, provides information and resources to community residents and organizations, trains healthcare professionals in violence prevention, and focuses university faculty research on critical issues in family violence.

The Think First National Injury Prevention Foundation was founded by the American Association of Neurological Surgeons and the Congress of Neurological Surgeons. For the past 19 years, the Foundation has worked with schools in communities across the nation to help children and adolescents increase their knowledge of unintentional injuries. The Think First comprehensive injury prevention curriculum, implemented in schools nationwide, has increased knowledge of unintentional injury and decreased risk-taking behavior.7

Sharp On Survival expanded on the Think First program model by including injured individuals—VIPs—to educate about and help prevent injury by intentional violence. The ultimate goal of SOS is to prevent traumatic injuries among young people by teaching them to think first and use their minds to protect their bodies. SOS teaches young people about safety while fostering professional and personal growth among youth disabled by severe, life-altering trauma.

Think First curricula are based on Rosenstock’s Health Belief Model and incorporate three widely accepted approaches to injury prevention: delivering education, using engineered safety products, and supporting safety legislation.7, 8 The program also serves as a work re-entry program for the VIPs, allowing them to realize their potential as productive members of society. Their participation in the program increases their self-esteem and feelings of self-worth, and decreases depression.

Research conducted by SOS since 1998 demonstrates the effectiveness of the curriculum in increasing injury prevention knowledge and decreasing risk-taking behaviors.7, 9 In 2002, the California Department of Education recognized Think First for Kids as a research-validated program and made the curriculum available for loan throughout the state in its California Healthy Kids Resource Center.

Mobilizing San Diego 

The 2003 Youth Risk Behavior Survey, conducted by the CDC, indicated that youth in San Diego were engaging in high-risk and violent behaviors.10 In fact, San Diego had the second highest rate of juvenile arrests in the state of California in 2003 (57.9/1000) and, after declining for several years, gang activity was on the rise in San Diego. In the first half of 2004, the San Diego Police Department reported a 10% increase in gang-related crime compared with the same period in 2003.11

Following the high school shootings in San Diego in 2001, nonprofit organizations in the county redoubled their efforts to improve communication and resource sharing among violence prevention activities and programs. A series of dialogues revealed that many of the violence prevention efforts underway in San Diego County were working in isolation, without a forum to connect with one another to learn about and share current “best practices” and other resources that could assist in improving their programs.

The UCSD ACE partnered with local nonprofit organizations addressing youth violence to establish the San Diego Coalition to Prevent Youth Violence (CPYV), a collaborative of grassroots organizations working with youth in the community. CPYV convenes monthly meetings to provide capacity building around various issues (e.g., program assessment, grant writing, reallocation and realignment of existing resources) and provides a forum for facilitating collaborative initiatives. The collaborative goals of CPYV are to (1) increase the effectiveness of violence prevention programs and services offered to youth and communities; (2) engage communities and community-based organizations through support and capacity-building efforts; (3) identify and improve access to youth violence prevention programs; and (4) serve as a catalyst for the promotion of peace.

CPYV partners identified several priority areas to address the issue of youth violence in San Diego, including a recommendation to training healthcare professionals more effectively in the area of youth violence. UCSD ACE and SOS, both on the Governing Board of CPYV, responded to this request by designing new and creative methods to train students in the UCSD School of Medicine.

Voices for Injury Prevention in Medical Education 

To assess the current status of violence prevention education in the School of Medicine, UCSD Division of Community Pediatrics surveyed medical student course directors to determine what courses in the School of Medicine were teaching about violence issues affecting children. Courses surveyed included all required clinical clerkships as well as required preclinical courses where violence might be taught (e.g., Introduction to Clinical Medicine, Doctor–Patient Relationship, Human Growth and Development). Course directors were asked to comment on the amount and type of teaching addressing the following aspects of violence affecting youth: child abuse, intimate partner violence, suicide, peer violence, and gang affiliation. Qualitative analysis of the survey results revealed no sequential thematic coordination for youth violence prevention curricula throughout the medical school and an overall lack of youth violence prevention education. The limited education addressing violence primarily covered suicide, intimate partner violence, and child abuse. No formal sessions specifically addressed youth peer violence.

With these data compiled, a proposal for increased training addressing youth violence was submitted to the School of Medicine and a half-day workshop covering youth violence was inserted into a new fourth year course, From Principles to Practice. All fourth-year medical students attend this course, designed to integrate basic scientific principles and evidence-based medical knowledge into clinical practice. The course also provides the opportunity for training in topics not previously addressed in the medical school curriculum. The overall aim of the workshop is for medical students to recognize their future roles in youth violence prevention, regardless of their career choices.

The first such youth violence workshop was divided into two parts. The first part was a facilitated small group discussion of a case of a pre-adolescent victim of violence. This part of the workshop focused on identification of youth violence risk and protective factors. Teaching points included different levels for prevention of youth violence (primary, secondary, and tertiary), effective interventions for youth violence prevention, and skills to examine intervention programs for effectiveness. Students received handouts describing risk and protective factors as well as effective and ineffective youth violence prevention programs. Most of this information was derived from the Surgeon General’s report on youth violence.2 In addition, handouts with screening tools and local youth violence prevention resources were distributed.

For the second part of the workshop, CPYV members played an integral role in the development of a multidisciplinary panel discussion with representatives from law enforcement, health care, mental health, social service agencies, juvenile justice, and public school officials with expertise in gang issues, as well as former gang member VIPs. Inclusion of the VIPs on the panel was based on the model of “expert patient,” an increasingly utilized technique for training in medical education.12, 13

The panel of community partners discussed opportunities for physicians to play an important role in youth violence prevention and intervention. They discussed the fact that physicians have a responsibility to be involved and that doctors can partner with community resources for youth violence prevention and intervention. Physicians are in a unique position because they can ask questions about whether a family or a child is at risk for violence. They should develop relationships with community-based organizations that provide services, to be able to send patients to specific contacts.

Panelists also advised that physicians talk with school principals about available resources, and as a means of connecting directly with schools. Physicians were also advised to team with police officers to help bring about needed changes.

VIPs from the SOS program, who, as former gang members, had been victims and perpetrators of youth violence, discussed the environment and influences that shaped the choices that led to their injuries. They recommended intervention strategies for physicians that might have made a difference in their own lives. The VIPs explained how to identify gang affiliation, opportunities to discuss risk factors for alcohol and other drug use, and questions to ask adolescent patients about their goals and dreams.

Franky, a 26-year-old paraplegic male with a T-2 injury from a gang-related gunshot wound, shared his story and challenged the medical students to have very specific, concrete discussions with their patients about violence. He was joined by Mark, a 19-year-old with traumatic brain injury from multiple gunshot wounds and battery with a baseball bat.

Both young men shared their pre-injury lifestyles and interests, which included “getting high, sex, partying, guns, gangs, and kickin’ back.” They both described themselves as risk-takers. They offered examples of missed opportunities for intervention in their own lives. They each saw medical professionals several times before their final life-altering injuries, but none talked to them about the bad choices they were making. The VIPs stressed the importance of physicians’ involvement in the effort to address youth violence. Franky said, “I figured it wasn’t ever going to happen to me, and it ended up happening to me when I was 17 years old. I’ve been in this wheel chair for nine years of my life and I can tell you that every day is a struggle.”

The VIPs indicated that a visit to the emergency room was an optimal time to intervene and that they would have been more likely to listen in that setting, though any physician has opportunities to have an impact. “If you guys see one of your patients that you think most likely is high risk…don’t hesitate to tell them, ‘What’s wrong with you, do you need help? Maybe I can find something that will help you,’” Franky advised. “There are lots of resources in the community that can help these people, and you can make a difference in their lives.” When a student asked how he could talk to youth about gangs when his own experience was limited to middle-class suburbia, Mark answered, “If you appear to be interested in our lives and ask simple questions about it, we’ll give you all the information you want.”

The workshop has continued, with minor revisions in the delivery of content and composition of the panel, for five years. Evaluation of the first two workshops focused on process measures as a part of the larger course evaluations. In subsequent years a retrospective pre/post evaluation was added, addressing medical students’ role in youth violence prevention as well as knowledge of risk and protective factors and prevention and treatment resources for youth violence.14 This evaluation method was chosen because of the short nature of the intervention and because of the workshop aim of changing attitudes and practices. The retrospective pretest allowed participants to reflect on their knowledge and attitudes before the workshop, and the posttest measured these factors after the workshop (Table 1). Descriptive statistics were used to analyze data from the last three years of workshops. The means for the responses before and after the workshop were calculated. A paired t-test was performed for the responses to each statement. A change score was also calculated for each student who completed the survey, to determine the self-assessed change in agreement to each statement. Over three years of data collection, response rate averaged 60% of graduating students.

Table 1. UCSD fourth year medical students’ workshop scores assessing attitude and knowledge about youth violence prevention

	Statement	Mean⁎		Positive change score (% of respondents)
		Before	After
	As a physician, I will have an important role in youth violence prevention.	3.1	3.4	34.4
	I am knowledgeable about risk factors for involvement in youth violence.	2.6	3.4	69.4
	I am knowledgeable about protective factors for involvement in youth violence.	2.5	3.4	73.8
	I am knowledgeable about prevention programs for youth violence.	2.1	3.0	69.9
	I feel confident I can identify resources in the community regarding youth violence.	2.3	3.1	66.7

1=strongly disagree; 2=disagree; 3=agree; 4=strongly agree.

⁎ Comparison of means before and after are statistically different (p<0.05).

Best Practices 

Published evidence of effective, replicated strategies to teach youth violence prevention to healthcare professionals is sparse.6 As mentioned earlier, the decision to include the VIPs on the panel was based on the model of the “expert patient.” A growing body of evidence suggests that participation of consumers and patients in training healthcare professionals can contribute important and different learning opportunities. Their expertise is defined by experience, and provides a unique perspective to the students. Practitioners trained by consumers have been shown to develop better communication skills, professional attitudes, empathy, and clinical skills.12 UCSD ACE faculty adapted this model and built on their previous success in using local community partners to act as teachers and experts for pediatric residency training, and turned to their community partners for resources to address youth violence.15 Our preliminary data indicate that this adaptation of the “expert patient” model is an effective method of teaching youth violence prevention to senior medical students.

Lessons Learned 

Five years of implementing this youth violence prevention training have taught UCSD ACE and its community partners several lessons: (1) People affected by violence are good teachers about violence prevention, when given a forum for sharing their perspectives and experiences. VIPs, in particular, offer real and powerful stories, through first-hand accounts of their violence-related disabilities and the impact on their daily lives. (2) Because health professionals have limited time for preventive care, it is important to teach them to get involved in issues affecting their patients and to utilize community resources. (3) Experiential learning opportunities for health professionals are a component of effective training, grounding theory in real world practice. The last year of medical school offers an opportunity for students to integrate this information with previous clinical experiences and to plan how to incorporate youth violence prevention into future practice. To more fully evaluate this method of teaching, implementation of a similar curriculum with pediatric residents would allow for a more robust evaluation, with detection of abuse as an outcome variable in addition to the self-reported changes in attitude described in this paper.

Conclusion 

To be effective in violence prevention, community mobilization needs to engage multiple sectors. In San Diego, a community-based coalition partnered with the UCSD School of Medicine to train health professionals about risk and protective factors and violence prevention. Together, an innovative curriculum was designed that allows traumatically injured youth to speak directly to medical student trainees. Youth disabled by violence are effective spokespeople and, with the SOS program, have also become accomplished trainers.

The VIPs tell their stories and challenge the health professionals to get involved and take action. VIPs are an effective part of training the next generation of physicians to be involved, knowledgeable about the risk and protective factors, able to recognize risk when they see it, and able to intervene effectively.

Violence statistics adequately describe the scope of the problem of youth violence but such data lack emotional impact. Using personal stories to demonstrate the effect that violence has on individuals is a valuable training tool. VIPs are a powerful way of humanizing the profound impact of violence, the opportunity physicians have for intervention, and the responsibility that physicians have to directly address adolescents at risk. Evaluation of the curriculum demonstrated that UCSD medical students learned about risk and protective factors and were personally moved by the workshop. They were also more confident about identifying community resources to aid them in becoming violence-prevention advocates.