Getting to the Core of the Women's Curriculum—It's Time to Change the Way We Train Our Fellows

In the United States, 50.7 percent of the population arewomen [1]. In 2004 there were an estimated 104 millionvisits for evaluation and management of a digestive dis-ease, and after adjustment for age the number of visits was10 percent higher for women than for men, which equatesto over 57 million visits per year for women [2]. Althoughmany digestive diseases are the same in men and women,there are also many differences. Research has shown thatthere are gender differences in epidemiology, response tohealth and illness, treatment, and complications. Fertility,pregnancy, and the post-partum state pose speciﬁc chal-lenges for gastroenterologists. As specialists in digestivediseases, gastroenterologists must have the knowledge andrange of skills necessary to care for women with theirunique issues.It is challenging to successfully train highly qualiﬁedgastroenterologists during the three year fellowship period.An enormous amount of knowledge and procedural skillsmust be acquired by the end of training, with the instilla-tion of a desire for life-long learning. A program must bewell-structured with a committed program director anddedicated faculty in order to accomplish these objectives.Guidelines for training gastroenterology fellows wereﬁrst published by the Gastroenterology Leadership Councilin 1996, but it was not until the Gastroenterology CoreCurriculum was updated in 2003 that a women’s curriculumin digestive diseases was ﬁrst outlined. The recommenda-tionsspeciﬁcallyaddressedthreeareas:(1)generalwomen’sgastroenterology (GI) health issues, including the doctor–patient relationship; cultural, religious, and psychosocialissues; differences in disease presentation; laboratory anddiagnostic testing; and the use of complementary and alter-native medicine; (2) speciﬁc women’s GI health issuesincluding gender differences in GI health and disease states,the effects of the menstrual cycle and menopause on GIhealth and disease states, medication pharmacokinetics, andresponse to and complications of therapy; and (3) pregnancyand childbearing issues, including fertility, infertility, preg-nancyinwomenwithpreexistingdigestivediseases,diseasesunique to pregnancy, medication pharmacokinetics andsafety during pregnancy and with breast-feeding, clinicalonset of digestive diseases during pregnancy and afterdelivery, and the effect of pregnancy on healthy mothers.The training recommendations included obtaining theappropriate knowledge and clinical experience throughdidacticlecturesandclosealliancewithphysicianswhohavean interest and experience in evaluating and managingwomen’s GI health issues, including obstetricians andgynecologists. Another recommendation was that a mini-mum of 25% of the fellow’s panel of patients be women [3].In July 2005, the ACGME adopted these recommenda-tions and now requires formal instruction and clinicalexperience in women’s GI health issues and that in theircontinuity clinic ‘‘each fellow’s panel of patients mustinclude at least 25% of patients from each gender’’ [4].In 2008, the ﬁrst survey assessing compliance with theGastroenterology Core Curriculum was published [5]. Thisstudy evaluated overall programmatic compliance with afocus on the hepatology component and found thatalthough most programs were in general compliance withthe recommendations of the Core Curriculum, and specif-ically the hepatology portion, there were striking deﬁ-ciencies noted in some areas of hepatology training.Although this study was somewhat reassuring, the areaswhere there were shortcomings needed improvement [5].