According to recent estimates, more than 125,000 sexual assaults occur each year in the United States. “Emergency physicians (EPs) work closely with law enforcement in sexual assault cases because these victims often present to EDs for evaluation,” says Margaret K. Sande, MD, MS. “Documentation and testimony in sexual assault cases from EPs is valuable for the prosecution of offenders.” She adds that studies demonstrate that accurate and thorough documentation of sexual assault injuries correlates with higher rates of charges filed and successful convictions of perpetrators.
The American Board of Emergency Medicine’s Model of Clinical Practice of Emergency Medicine includes the assessment of sexual assault and completion of examinations for these events as integral topics and skills during the training of emergency medicine (EM) residents. However, Dr. Sande says there are no nationally recognized recommendations on the number of hours or content that should be dedicated to training. She notes that some EM residents may not feel properly prepared to perform the complex forensic examinations often required for sexual assault patients.
Over the last 35 years, sexual assault nurse examiner (SANE) programs have been established to improve the quality of care for sexual assault victims. Throughout the country, these programs have quickly become the model of care for assault victims, but few analyses have explored how they impact EM resident training. In a study published in the Western Journal of Emergency Medicine, Dr. Sande and colleagues gathered information from program directors of EM residency programs in the U.S. to assess current training for the care of sexual assault. They also surveyed program directors on their views of the overall impact of SANE programs on EM resident training.
According to findings, nearly one-third of program directors reported that their residency did not require procedural competency for the sexual assault exam (Table 1). Another 41% reported that their residents were required only to observe the completion of sexual assault exams in order to demonstrate competency. When residency program directors were asked how their programs established resident requirements for sexual assault exams, 52% did not know how these requirements were established (Table 2).
A Help or Hindrance?
Residency program directors of institutions with SANE programs had varied opinions as to whether SANE programs helped or hindered resident education. The majority of respondents felt these programs have had no effect on the education of EM residents on sexual assault examinations. Several themes were also generated from these responses (Table 3). “While SANE programs have been shown to enhance patient care and the accuracy of evidence collection, it’s possible that they may decrease EM resident exposure to these cases,” says Dr. Sande. “In turn, this can affect how competent and comfortable they are with performing forensic exams.”
Increasing the Dialogue
Dr. Sande notes that the majority of responding program directors who participated in the study reported working at institutions with SANE programs, but many physicians may ultimately practice in settings where there is no such program. Given the overall success of SANE programs to date, it is anticipated that SANE programs will continue to coexist at EM residency training sites. “The results of our study should spur conversation among residency program leadership about the status of their own sexual assault educational initiatives,” says Dr. Sande. “Our hope is that these findings can serve as a catalyst for national EM graduate medical education groups to convene and assess the need for a national training model in sexual assault education.”
“The results of our study should spur conversation among residency program leadership about the status of their own sexual assault educational initiatives.”
Resident training with a SANE nurse can be an excellent opportunity to learn how to proficiently perform exams, according to Dr. Sande. “A combination of case observation, completion of patient exams, and collection of evidence will be necessary to optimize the care of sexual assault cases. If SANE programs continue to thrive, broader support for more formal training of EM physicians in partnership with affiliate SANE programs may prove to be worthwhile.”
Findings of the study also highlight the need for more research on the impact of SANE programs on resident competency in treating and examining sexual assault patients. “In order to better elucidate the effect of SANE programs on resident training, future work should be targeted to senior residents and recent graduates so we can directly ascertain the comfort level of physicians coming from residency training programs with and without SANE programs,” Dr. Sande says. “We also need analyses on residents at SANE programs before and after they are implemented. These types of projects may more directly assess the true impact of SANE programs on EM residents and allow us to better assess EM resident preparedness for the care and examination of this important subset of patients.”
Readings & Resources (click to view)
Sande MK, Broderick KB, Moreira ME, Bender B, Hopkins E, Buchanan JA. Sexual assault training in emergency medicine residencies: a survey of program directors. West J Emerg Med. 2013;14:461-466. Available at: http://escholarship.org/uc/item/2zk3d6m6.
Campbell R, Patterson D, Lichty LF. The effectiveness of sexual assault nurse examiner (SANE) programs: a review of psychological, medical, legal and community outcomes. Trauma Violence Abuse. 2005;6:313-329.
Wiler JL, Bailey H. The need for emergency medicine resident training in forensic medicine. Ann Emerg Med. 2007;50:733-738.
McLaughlin SA, Monahan C, Doezema D, et al. Implementation and evaluation of a training program for the management of sexual assault in the emergency department. Ann Emerg Med. 2007;49:489-494.
Young S, Wells D, Summers I. Specific training in clinical forensic medicine is useful to ACEM trainees. Emerg Med Australas. 2004;16:441-445.