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AAMC Reporter: December 2005
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Stephen Hargarten, M.D., M.P.H., Medical College
of Wisconsin
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Teaching Future Doctors About Injury
Needs Integrated Approach, AAMC Report Says
By Anne Blank, Special to the Reporter
A 12-year-old girl with a history of being physically
abused is referred to a psychiatrist for depression and
poor academic performance. An elderly man requires hip replacement surgery after
tripping on a loose rug. A teenage driver is killed and his passenger critically
injured after their car is hit by another vehicle
whose driver had a blood alcohol level well above
the legal limit.
Those are the kinds of injury-related challenges
confronting physicians every day. And aside from
the personal trauma and tragedy involved, what they
all have in common is that — with certain precautions —
they could have been prevented, according to
a report developed by the AAMC with funds from the
National Center for Injury Prevention and Control of
the Centers for Disease Control and Prevention (CDC).
The report, Training Future Physicians About Injury,
was prepared by a multidisciplinary group appointed by
the AAMC and the CDC. The panel urged medical
schools to teach students systematically how to recognize,
prevent, and treat injuries.
"Attention to this biosocial disease burden in the
curriculum of medical schools has lagged," said panelist
Stephen Hargarten, M.D., M.P.H., professor and chair of
the Department of Emergency Medicine at the Medical
College of Wisconsin, where he also is director of the
Injury Research Center. "It is time to call attention to
this much-needed effort to integrate injury control and prevention
principles and scientific thinking into the
curriculum of medical students."
Although injury prevention has been taught to some
extent in medical schools, it is not being taught comprehensively
enough, the report said. Many injury specialists
consider that surprising because, as the CDC has
found, injury is the nation's leading cause of death
and disability among young adults, adolescents, and
children. In fact, no age group is spared the effects of
injury — including the elderly, who may be more prone
than younger adults to falls and abuse. About 150,000
people in the United States die from injuries each year,
with motor-vehicle crashes being the leading cause of
injury-related deaths, says the CDC. Other significant
causes of injury include firearms, burns, drowning,
suffocation, and poisoning.
'We Haven't Changed'
"As we look over the last two decades or so, what's really
causing health problems in our society has changed, but
we haven't actually changed the focus of our training,"
said panelist Deborah Claire Stewart, M.D., associate
medical director of the Child and Adolescent Abuse,
Resource, Evaluation Diagnostic and Treatment Center,
which is part of the University of California, Davis,
Medical Center.
Part of the problem is that opportunities to prevent or
moderate the effects of injuries often go unrecognized,
said Rika Maeshiro, M.D., M.P.H., assistant vice president
for public health and prevention in the AAMC's Division
of Medical Education. "There still may be a sense, even
within the medical community, that injuries happen
without a pattern, and are uncontrollable — that they
are 'accidents,'" she observed. "Clearly, injuries do occur
with patterns — and more frequently in individuals and
populations with certain risk factors."
By recognizing those patterns, physicians could do more
to help prevent injuries from occurring in the first place,
Maeshiro added. Characteristics that may put patients at
greater risk for injury include age, gender, occupation,
pre-existing medical conditions, and behaviors.
Injuries may be unintentional or intentional, and they
may involve violence to others or to oneself, the AAMC-CDC
report noted. It defined injuries as "damage to the
body resulting from acute exposure to thermal, mechanical,
electrical, or chemical energy or from the absence of
such essentials as heat or oxygen."
Many diseases and traumas have some aspect that could
be classified as an injury and thus might be averted, the
report said. For example, a heart attack in a patient with
a family history of heart disease, who not only failed to
follow a recommended diet but also smoked, could be
viewed as an injury, rather than an accident. In fact,
the word "accident" does not appear once in the 20-page report.
"Injury consists of many different things," said Rajeev
Sabharwal, M.P.H., associate director of educational
research and evaluation in the AAMC's Division of
Medical Education. "If you align your thinking that way,
you may see something that you didn't necessarily think
was an injury."
Because injuries underlie so many health conditions, the
report called for integrating prevention and treatment
throughout the medical school curriculum, rather than
trying to teach it as a separate subject. Said Maeshiro:
"We emphasize the need to integrate this topic into the
curriculum both longitudinally and laterally."
In the teaching of injury prevention, experts say, injuries
should be viewed in a matrix-type fashion. A guiding
principle in the report is that injuries are not isolated
events but are directly related to risky lifestyle choices
and behaviors that precede them, as well as to the damage
that ensues.
To help students visualize the connection between
behavior and injury, the panel used a table known
as the Haddon Matrix, which was developed in the
1960s by William Haddon, Jr., M.D., M.P.H., the first
administrator of the National Highway Traffic Safety
Administration and a founder of modern injury
research. Using the matrix, students can plot events
that occurred immediately before and during an injury,
as well as psychological, emotional, and physical consequences.
Such an approach allows students to see the
association between events and outcomes, said Stewart
of the University of California, Davis,Medical Center.
Doctors can use the matrix to identify patients exhibiting
an increased risk for injury and thus can seek to prevent
injuries from occurring. But at the same time, the AAMC
report said, doctors should not be judgmental in communicating
and interacting with their patients.
The AAMC report is available from AAMC Publications.
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