Women's health education: progress and promises.

Prior to 1990, women's health, as we now know it, did not exist in the collective consciousness of internal medicine physicians as a topic to be highlighted in medical education. Indeed, we hadn't even thought of many of the important questions about women's health that are now being asked. We were not aware that a glaring deficit existed in our curricula. Internal medicine was taught, for the most part, in a unisex fashion. Yes, some diseases were more common in men or women, but we didn't treat diseases differently based on patient sex, nor did we ask why the differences existed. Yes, women's care was complicated by hormonal fluctuations, but for the most part that was the purview of obstetrics and gynecology and was not our concern. We taught that coronary artery disease (CAD) was primarily a disease of men. The 1990s witnessed new beginnings for women's health in internal medicine, and the birth of women's health education as a topic of academic focus. Two of the great movements that led to this change were the recognition of the need for women's health and gender-based research and education at the national level and the rise of primary care in internal medicine. Congress mandated the former, and provided dollars to fuel an explosion of research and public awareness campaigns in women's health. The mandate for women's health research included every organ system, and the psychosocial aspects of health. As more internists practiced as primary care physicians to women, it became clear that the ability to perform a breast examination and a Pap smear, while essential, was not sufficient to provide comprehensive primary care to women. This edition of JGIM has 3 articles on women's health that highlight important issues in women's health education. Dixon's report, “Teaching Women's Health Skills: Confidence, Attitudes, and Practice Patterns of Academic Generalist Physicians,” underscores the need for faculty development in women's health.1 One could hardly expect to train internists in the care of women patients if faculty did not exist who possess the knowledge and necessary skills to provide gender-specific care. In his survey, the majority of academic general internists reported comfort performing breast and pelvic exams, but only 22%, 21%, and 45% reported comfort assessing dysfunctional uterine bleeding, prescribing Depo-provera, or instituting oral contraceptives, respectively. Internists felt less well trained to perform bimanual examinations, were less likely to think that performing Pap smears was a “good use of their time,” and were less likely to report that their clinics were equipped to perform gynecologic examinations than were their family physician counterparts. Orsetti's article, “Impact of a Veterans Affairs Continuity Clinic on Resident Competencies in Women's Health,” reports that residents whose continuity clinics were held at the VA hospitals felt less competent to deal with women's health issues than their counterparts who practiced in a mixed-sex clinic.2 Differences existed for all areas: counseling skills for violence and other issues, general knowledge of women's health issues, and skills in the examination of women patients. Differences persisted despite efforts to add women's health topics to the overall curriculum and to add rotations addressing women's health for the residents. The Residency Review Committee in internal medicine has stated, “Residents should receive instruction and clinical experience in the prevention, counseling, detection, and diagnosis and treatment of gender-specific diseases of women and men. (NOTE: This clinical experience may occur in general medicine clinics or other specialty clinics.”).3 The wording of this requirement leaves much room for interpretation and clinical variation. The results of the studies noted above should be taken into consideration when clinical experiences are fashioned for residents. Clinical experiences with women patients on an ongoing rather than an intermittent basis, with clinical faculty who are confident in their own skills, and in clinics that are equipped to perform gynecologic services are essential for residents to acquire confidence in addressing women's health issues. Finally, the article by Harrold, et al., “Narrowing Gender Differences in Procedural Utilization in Acute Myocardial Infarction: Insights From the Worcester Heart Attack Study,” provides hope that disparities in the care of women will lessen as education for internal medicine physicians contains more women's health– and gender-based medicine content.4 In this study of practice patterns in the 1990s, women overall were less likely to undergo exercise stress testing, cardiac catheterization, or coronary artery bypass grafting than were their age-matched male counterparts. This gap lessened, however as the decade progressed, and by 1999, women were treated similarly to male patients. Although not studied as a variable, increased education of physicians and public awareness of CAD in women in the 1990s undoubtedly affected these outcomes. During this time, for example, the fact that CAD is the leading cause of death in women became much better known.5 Our work in women's health education is far from finished. The American Board of Internal Medicine has recommended that women's health core competencies be covered in residency curricula, but at present this is treated as a suggestion rather than as a requirement.6 Women's health education programs exist within some academic centers, but are essentially non-existent in others. The content of women's health curriculum can be problematic because of rapid changes (e.g., hormone replacement therapy), lack of evidence-based data on many women's health issues, and a lack of consensus about which topics are critical to internal medicine training. Additionally, we have yet to build the critical mass of internal medicine educators who are fully equipped to teach women's health that is necessary to educate all internal medicine physicians in the gender-based care of women patients. The Women's Health Education Interest Group was formed within the Society of General Internal Medicine (SGIM) in 2001 to foster the ability of women's health educators to network, share resources, lobby, develop uniform curricula, and keep abreast of scientific discoveries. Additionally, the SGIM annual meeting program provides many faculty development opportunities in women's health. SGIM, along with other national organizations, is helping to achieve the promise of providing all physicians with a solid foundation for providing the gender-sensitive and gender-specific care that women want and expect.