What internists need to know: core competencies in women's health. ABIM Subcommittee on Clinical Competence in Women's Health

Position Paper: SGIM Sex- and Gender-Based Women's Health Core Competencies

Women's health care has evolved significantly since it was first acknowledged as an integral part of internal medicine training more than two decades ago. To update and clarify core competencies in sex- and gender-based women's health for general internists, the Society of General Internal Medicine (SGIM) Women and Medicine Commission prepared the following Position Paper, approved by the SGIM council in 2023. Competencies were developed using several sources, including the 2021 Accreditation Council for Graduate Medical Education Program Requirements for Internal Medicine and the 2023 American Board of Internal Medicine Certification Examination Blueprint. These competencies are relevant to the care of patients who identify as women, as well as gender-diverse individuals to whom these principles apply. They align with pivotal advances in women's health and acknowledge the changing context of patients' lives, reaffirming the role of general internal medicine physicians in providing comprehensive care to women.

Mini-Residencies to Improve Care for Women Veterans: A Decade of Re-Educating Veterans Health Administration Primary Care Providers

Background: Many primary care providers (PCPs) in the Veterans Health Administration need updated clinical training in women's health. The objective was to design, implement, and evaluate a training program to increase participants' comfort with and provision of care to women Veterans, and foster practice changes in women's health care at their local institutions. Methods: The Women's Health Mini-Residency was developed as a multi-day training program, based on principles of adult learning, wherein knowledge gleaned through didactic presentations was solidified during small-group case study discussions and further enhanced by hands-on training and creation of a facility-specific action plan to improve women Veterans' care. Pre, post, and 6-month surveys assessed attendees' comfort with and provision of care to women. The 6-month survey also queried changes in practice, promulgation of program content, and action plan progress. Results: From 2008 to 2019, 2912 PCPs attended 26 programs. A total of 2423 (83.2%) completed pretraining and 2324 (79.3%) completed post-training surveys. The 6-month survey was sent to the 645 attendees from the first 14 programs; 297 (46.1%) responded. Comparison of pre-post responses indicated significant gains in comfort managing all 19 content areas. Six-month data showed some degradation, but comfort remained significantly improved from baseline. At 6 months, participants also reported increases in providing care to women, including performing more breast and pelvic examinations, dissemination of program content to colleagues, and progress on action plans. Conclusions: This interactive program appears to have been successful in improving PCPs' comfort in providing care for women Veterans and empowering them to implement institutional change.

A Novel Contraception Counseling and Shared Decision-Making Curriculum for Internal Medicine Residents

INTRODUCTION

Many women of reproductive age with complex medical conditions receive primary care through an internal medicine (IM) physician rather than an obstetrician/gynecologist. Long-acting reversible contraception methods are the most effective form of contraception; however, IM residents are not routinely trained in them. Infrequent training in, inadequate knowledge of, and discomfort with contraception counseling limit the counseling performed by IM residents. Shared decision-making (SDM) is a method of patient-centered communication that can improve communication about patient preferences and increase patient satisfaction with and adherence to contraception. We developed a curriculum to teach contraception counseling under the framework of SDM for IM residents.

METHODS

The curriculum focused on contraception counseling through the lens of SDM designed for IM and medicine/pediatrics residents (PGY 2-PGY 4). We adapted an existing seven-step model of SDM to fit elements of contraception counseling. The curriculum consisted of a didactic teaching session with integration of an instructional video and structured interactive discussion. The session lasted 60 minutes.

RESULTS

Fifty-eight residents participated in the curriculum. On pre- and postcurriculum surveys, residents reported improvement in contraception knowledge (overall mean precurriculum = 57%, postcurriculum = 70%, p < .001) and comfort with contraception counseling (overall mean precurriculum = 3.2, postcurriculum = 3.6, p < .01). Residents expressed strong support for SDM before and after the curriculum.

DISCUSSION

Based on the survey results, the curriculum successfully addressed gaps in residents' comfort with contraception counseling and knowledge of contraception side effects and efficacy.

Women's Health Curricula in Internal Medicine Residency Programs: A Scoping Review

Background: Despite national efforts to expand women's health education, internal medicine (IM) residents remain unprepared to provide comprehensive care to women. The objectives of this scoping review are to provide an overview of published women's health curricula in IM residency programs and to identify potential areas for improvement. Materials and Methods: Studies were identified using PubMed, Embase, Cochrane Library, Scopus, Education Resources Information Center (ERIC), Web of Science, and MedEdPORTAL. Inclusion criteria included the following: (1) women's health as defined by the authors (2) description of a curriculum (3) designed for IM residents (4) based in North America, and (5) published between 1998 and 2018. Data abstracted included content, educational and assessment methods, and quality. Descriptive analysis was used to compare data. Results: Sixteen articles met the inclusion criteria. The most common women's health topics were intimate partner violence (31%) and menopause (31%). Twelve curricula (75%) were implemented in the outpatient setting. Of the teaching methods, didactics (69%) and in-clinic teaching (44%) were most commonly used. All studies that assessed attitudes, knowledge, and/or behavior showed an improvement post-intervention. No studies evaluated patient outcomes. Conclusion: To our knowledge, this is the first review summarizing published women's health curricula in IM residency. There were a limited number of published articles describing women's health curricula. Although content varied, the curricula were effective in improving attitudes, knowledge, and/or behavior with regard to women's health topics. We encourage IM residency programs to develop and disseminate women's health curricula to inform future improvements and advancements in women's health education.

Impact of Contraceptive Counseling in Clinical Settings: A Systematic Review

CONTEXT

This systematic review evaluated the evidence on the impact of contraceptive counseling provided in clinical settings on reproductive health outcomes to provide information to guide national recommendations on quality family planning services.

EVIDENCE ACQUISITION

Multiple databases were searched during 2010-2011 for peer-reviewed articles published in English from January 1985 through February 2011 describing studies that evaluated contraceptive counseling interventions in clinical settings. Studies were excluded if they focused primarily on prevention of HIV or sexually transmitted infections, focused solely on men, or were conducted outside the U.S., Canada, Europe, Australia, or New Zealand.

EVIDENCE SYNTHESIS

The initial search identified 12,327 articles, of which 22 studies (from 23 articles) met the inclusion criteria. Six studies examined the impact of contraceptive counseling among adolescents, with four finding a significant positive impact on at least one outcome of interest. Sixteen studies examined the impact of counseling among adults or mixed populations (adults and adolescents), with 11 finding a significant positive impact on at least one outcome of interest.

CONCLUSIONS

Promising components of contraceptive counseling were identified despite the diversity of interventions and inability to compare the relative effectiveness of one approach versus another. The evidence base would be strengthened by improved documentation of counseling procedures; assessment of intervention implementation and fidelity to put study findings into context; and development and inclusion of more RCTs, studies conducted among general samples of women, and studies with sample sizes sufficient to detect important behavioral outcomes at least 12 months post-intervention.

Contraceptive counseling by general internal medicine faculty and residents

BACKGROUND

Almost half of US pregnancies are unintended, resulting in many abortions and unwanted or mistimed births. Contraceptive counseling is an effective tool to increase patients' use of contraception.

METHODS

Using an online 20-item questionnaire, we evaluated the frequency of contraceptive counseling provided to reproductive-age women during a prevention-focused visit by University of Colorado internal medicine resident and faculty providers. We also evaluated factors hypothesized to affect contraceptive counseling frequency.

RESULTS

Although more than 95% of the 146 medicine faculty and resident respondents agreed that contraceptive counseling is important, only one-quarter of providers reported providing contraceptive counseling "routinely" (defined as ≥80% of the time) to reproductive-age women during a prevention-focused visit. Providing contraceptive counseling routinely was strongly associated with taking an abbreviated sexual history "often"/"routinely" (odds ratio [OR]=11.6 [3.3 to 40.0]) and with high self-efficacy to provide contraceptive counseling (OR=6.5 [1.5 to 29.0]). However, fewer than two-thirds of providers reported taking an abbreviated sexual history "often"/"routinely." More than 70% of providers reported inadequate knowledge of contraceptive methods as a contraceptive counseling barrier. However, providers' perceived inadequate knowledge was not associated with traditional educational exposures, such as lectures and women's health electives.

CONCLUSIONS

In prevention-focused visits with reproductive-age women, a minority of internal medicine faculty and residents reported routine contraceptive counseling. Future efforts to increase contraceptive counseling among internists should include interventions that increase provider contraceptive counseling self-efficacy and ensure that providers obtain an abbreviated sexual history.

Needs and priorities in women's health training: perspectives from an internal medicine residency program

BACKGROUND

Few studies have examined residents' perspectives on the adequacy of women's health (WH) training in internal medicine (IM). This study sought residents' opinions regarding comfort level managing 13 core WH topics, their perceived adequacy of training in these areas, and the frequency with which they managed each topic. The association between reported comfort level and perceived adequacy of training and management frequency was also assessed.

METHODS

A 67-item questionnaire was administered from April to June 2009 to 100 (64%) of the 156 residents from the traditional, primary care, and IM-pediatrics residency programs at a single institution. Descriptive and correlation statistics were used to examine the relationships between self-reported comfort level, perceived adequacy of training opportunities, and frequency managing WH issues. Data was stratified by sex, IM program, and post-graduate year (PGY).

RESULTS

The majority of residents reported low comfort levels managing 7 of 13 topics. Over half of residents perceived limited training opportunities for 11 of 13 topics. With the exception of cardiovascular disease in women, greater than 75% of residents reported managing the 13 topics five or more times in the prior 6 months. Correlation analysis suggested a linear relationship between low comfort levels and limited training opportunities, and between low comfort levels and low frequency managing WH topics (r=0.97 and r=0.89, respectively). Stratified analyses by sex, IM program, and PGY showed no significant differences.

CONCLUSIONS

Key gaps remain in WH training. Our results emphasize the importance of reinforcing WH training with hands-on management opportunities. Understanding institution-specific strengths and weaknesses may help guide the development of targeted initiatives.

Meeting the need for women's health training in gastroenterology: creation of a women's digestive disorders program at Brown University

BACKGROUND

Despite training requirements, knowledge and self-efficacy in women's health issues remain inadequate in many fields. In gastroenterology, nearly 60% of patients are women, and many disorders are more common in women. Adequate training in gastrointestinal (GI) women's health is, therefore, critical for gastroenterologists.

OBJECTIVES

(1) To create a core faculty in GI women's health, (2) to develop a GI women's health curriculum, (3) to provide didactic education and clinical experiences in GI women's health, (4) to produce self-efficacy in the evaluation and management of GI women's health issues, and (5) to develop academic gastroenterologists focused on GI women's health.

METHODS

We assembled a multidisciplinary group of GI women's health experts dedicated to training and mentoring GI fellows. We also held focus groups to determine the unmet needs in the management of the GI health of female patients in our community. Results from this needs assessment formed the foci of our program. In 2002, we introduced a 2-month rotation in GI women's health. Then, in 2005, we introduced a 3-year women's health pathway for trainees committed to academic careers.

RESULTS

Between 2002 and 2008, 13 fellows who participated in the rotation have graduated from the Brown GI fellowship program, and 1 has completed the track. Satisfaction with the program is high. Postgraduation survey results show that >80% of graduates who participated in the rotation feel prepared to evaluate and treat GI disorders in pregnancy, and nearly 65% feel prepared to address general GI women's health issues. All respondents report the GI women's health rotation provided training that was otherwise not addressed during fellowship.

CONCLUSIONS

A training experience in GI women's health can be created using local resources and expertise. Gastroenterologists with this training feel prepared to evaluate and manage the spectrum of women's health issues encountered in practice.

Women's health training in gastroenterology fellowship: a national survey of fellows and program directors

BACKGROUND AND AIMS

The Gastroenterology Core Curriculum requires training in women's digestive disorders; however, requirements do not necessarily produce knowledge and competence. Our study goals were: (1) to compare perceptions of education, fellow-reported levels of competence, and attitudes towards training in women's gastrointestinal (GI) health issues during fellowship between gastroenterology fellows and program directors, and (2) to determine the barriers for meeting training requirements.

METHODS

A national survey assessing four domains of training was conducted. All GI program directors in the United States (n = 153) and a random sample of gastroenterology fellows (n = 769) were mailed surveys. Mixed effects linear modeling was used to estimate all mean scores and to assess differences between the groups. Cronbach's alpha was used to assess the consistency of the measures which make up the means.

RESULTS

Responses were received from 61% of program directors and 31% of fellows. Mean scores in perceived didactic education, clinical experiences, and competence in women's GI health were low and significantly differed between the groups (P < 0.0001). Fellows' attitudes towards women's GI health issues were more positive compared to program directors' (P = 0.004). Barriers to training were: continuity clinic at a Veteran's Administration hospital, low number of pregnant patients treated, low number of referrals from obstetrics and gynecology, and lack of faculty interest in women's health.

CONCLUSIONS

(1) Fellows more so than program directors perceive training in women's GI health issues to be low. (2) Program directors more so than fellows rate fellows to be competent in women's GI health. (3) Multiple barriers to women's health training exist.

Women's Health Curriculum for Internal Medicine Residents: Development, Implementation, and Evaluation

OBJECTIVE

Women's health knowledge and skills are important for physicians, but training is often inadequate. The objective of this project was to develop, implement, and evaluate a women's health curriculum for an internal medicine residency program.

METHODS

After assessing institutional factors, we developed a curriculum for a multidisciplinary clinical rotation with a web-based tutorial. We recruited faculty from several specialties relevant to the care of women to precept for the rotation and/or to provide teaching materials for the tutorial.

RESULTS

The curriculum for the 1-month rotation covered most of the recommended women's health topics. Internal medicine residents worked in a variety of clinical settings and were assigned to a web-based tutorial and a pretest and posttest. A statistically significant increase was seen in participants' mean posttest (71.7%) versus pretest (61.1%) scores (difference, 10.7%; 95% confidence interval [CI]: 4.7-16.6; P  =  .0009). No difference was seen in controls' mean posttest (56.5%) versus pretest (57.2%) scores (difference, -0.7%; 95% CI: -12.1-10.7; P  =  .9). Mean rotation evaluation responses ranged from 7.09 to 7.45 on a 9-point scale. The majority (93%) of survey respondents agreed that the rotation increased their skills in caring for women, and all agreed the program was well organized and that it increased their awareness of women's health issues.

CONCLUSION

A women's health curriculum using a web-based tutorial with a multidisciplinary clinical rotation can be successfully implemented in an internal medicine residency. The curriculum satisfied women's health training requirements, was associated with improvements in learning outcomes, and may be a model for women's health education.

Providers' perspectives on challenges to contraceptive counseling in primary care settings

BACKGROUND

Although three quarters of reproductive-age women see a health provider annually, less than half receive recommended contraceptive counseling services. We sought to explore providers' perspectives on the challenges to contraceptive counseling in primary care clinics to develop strategies to improve counseling services.

METHODS

A qualitative, focus group (n = 8) study was conducted in November and December 2007; 48 of 90 providers practicing in four primary care clinics at the University of Pittsburgh Medical Center participated. Providers included physicians, nurses, and pharmacists working in these clinics' multidisciplinary teams. Discussions explored perceived barriers to the provision of counseling services. All groups were audiorecorded, transcribed, and entered into Atlas.Ti, a qualitative data management software. The data were analyzed using a grounded theory approach to content analysis.

RESULTS

Perceived patient, provider, and health system barriers to contraceptive counseling were identified. Perceived patient barriers included infrequent sexual activity, familiarity with a limited number of methods, desire for pregnancy despite medical contraindications, and religious beliefs. Provider barriers included lack of knowledge, training, and comfort; assumptions about patient pregnancy risk; negative beliefs about contraceptive methods; reliance on patients to initiate discussions; and limited communication between primary care providers (PCPs) and subspecialists. Health system barriers included limited time and competing medical priorities.

CONCLUSIONS

PCPs vary widely in their knowledge, perceived competence, and comfort in providing contraceptive counseling. General efforts to improve integration of contraceptive counseling into primary care services in addition to electronic reminders and efficient delivery of contraceptive information are needed.

Primary care program directors' perceptions of women's health education: a gap in graduate medical education persists

BACKGROUND

Previous studies found that internal medicine residents are not adequately prepared to provide comprehensive primary care to women. The impact of subsequent national guidelines emphasizing women's health education during residency is unknown.

METHODS

We conducted a cross-sectional survey of primary care internal medicine residency program directors (PDs) in the United States. We asked the directors to provide information about themselves and their programs, to rate how strongly they agreed that residents should master each of 13 women's health competencies, to estimate the proportion of their residents who actually master each competency by the end of their residency, and to indicate means by which each competency was taught (articles, lectures, patient care, specialty clinic, other).

RESULTS

Of 69 directors contacted, 42 (61%) responded. Most respondents agreed that residents should master all 13 competencies. However, there were significant discrepancies (p < 0.001) between the proportion of respondents who believed their residents should master competencies concerning 10 of 13 women's health topics and the proportion who believed their residents actually did master them. More than one third of PDs estimated that the majority of their residents would not gain the knowledge to diagnose, treat, or counsel women with incontinence, vaginitis, domestic violence, preconception planning, or birth control needs by the end of residency training. Of 18 potential predictors of quality education, only 2 proved significant: number of years the respondent served as program director (p = 0.02) and number of competencies taught by lecture (p = 0.007).

CONCLUSIONS

Despite national guidelines endorsing women's health education, a large discrepancy persists between what PDs believe their residents should master and what they estimate their residents actually master. This study suggests a need for substantial improvements in internal medicine residency training to adequately prepare residents to care for women.

Do Women's health internal medicine residency tracks make a difference?

BACKGROUND

Women's health tracks (WHTs) were developed to overcome identified deficiencies in residency training. Their effectiveness in preparing residents to manage both gender-neutral and gender-specific medical conditions is unknown.

METHODS

Using current guidelines for internal medicine training, we designed a 65-item survey to measure residents' knowledge, comfort levels, and referral patterns concerning two gender-neutral topics (diabetes and thyroid disease) and two gender-specific topics (polycystic ovarian syndrome [PCOS] and menopause). We administered it to postgraduate year 2 (PGY2) and PGY3 internal medicine residents at a large academic medical center and compared the results of WHT and non-WHT residents using chi-square and t tests.

RESULTS

Of 61 residents, 50 (82%) responded. Fifty percent of respondents were female, 62% were PGY3, and 36% were WHT. WHT residents had higher mean knowledge scores than non-WHT residents concerning PCOS (60% vs. 45%, p < 0.05) and menopause (73% vs. 60 %, p < 0.01), and they were more likely to report feeling "very comfortable" handling PCOS and menopause issues (43% vs. 18%, p < 0.02), including diagnosing PCOS, managing hot flashes, and managing vaginal atrophy. WHT residents were less likely than non-WHT to immediately recommend referrals if patients had suspected PCOS (0% vs. 19%, p < 0.03) or confirmed PCOS (0% vs. 32%, p < 0.02), and they were more likely to report feeling adequately trained to provide comprehensive ambulatory women's healthcare (73% vs. 7%, p < 0.001). There were no significant differences between WHT and non-WHT residents on gender-neutral topics.

CONCLUSIONS

A WHT can help improve competencies in selected areas of women's health without compromising residents' knowledge or comfort concerning two core gender-neutral topics in ambulatory medicine.

Internal medicine residents' preparedness to care for reproductive-age and pregnant women

BACKGROUND

Research that addresses whether residents are prepared to deliver preconception care and manage medical conditions in pregnant and postpartum women has been scarce since the publication of women's health competency guidelines for internists in 1997.

PURPOSE

To investigate current attitudes, training, and perceived preparedness in these areas and to explore relationships between resident characteristics and preparedness.

METHODS

A 62-item questionnaire was given to 105 internal medicine residents and recent graduates at two affiliated residency programs.

RESULTS

Eighty-five surveys were returned. Most respondents reported that they had minimal training and were unprepared in these areas but felt that learning these topics is important. Perceived preparedness correlated strongly with relevant didactic and clinical training but was not associated with gender, residency track, or career plan.

CONCLUSIONS

In light of published competency guidelines, internal medicine training programs should consider adding or increasing curricular content to improve residents' perceived preparedness to deliver care to reproductive-age and pregnant women.

The rectovaginal examination: physician attitudes and practice patterns

BACKGROUND

The value of screening with the rectovaginal examination (RVE) has not been validated. This study describes physician attitudes and practice patterns regarding the RVE.

METHODS

Cross-sectional survey of residents and faculty in general internal medicine and obstetrics/gynecology (OB/GYN) at a university hospital.

RESULTS

Thirty-four percent of physicians surveyed reported routinely performing the RVE. More OB/GYN than internal medicine physicians reported doing the RVE routinely (60% versus 27%, P = 0.02), and felt it provided additional information (80% versus 44%, P = 0.01). More respondents believed that it provides additional information to the routine pelvic examination (53%) than agreed with its routine inclusion (42%) or that reported routinely performing it (34%). (P = 0.0001)

CONCLUSIONS

More OB/GYN than internal medicine physicians routinely perform the RVE and believe it adds additional information to the routine pelvic examination. Additional research is indicated to determine if frequent omission of the RVE impacts women's health.

Web-based curriculum. A practical and effective strategy for teaching women's health

OBJECTIVE

To address the need for women's health education by designing, implementing, and evaluating a self-study, web-based women's health curriculum.

DESIGN

Cohort of students enrolled in the ambulatory portion of the medicine clerkship with comparison group of students who had not yet completed this rotation.

PARTICIPANTS/SETTING

Third- and fourth-year medical students on the required medicine clerkship (115 students completed the curriculum; 158 completed patient-related logs).

INTERVENTION

Following an extensive needs assessment and formulation of competencies and objectives, we developed a web-based women's health curriculum completed during the ambulatory portion of the medicine clerkship. The modules were case based and included web links, references, and immediate feedback on posttesting. We discuss technical issues with implementation and maintenance.

MEASUREMENTS AND MAIN RESULTS

We evaluated this curriculum using anonymous questionnaires, open-ended narrative comments, online multiple-choice tests, and personal digital assistant (PDA) logs of patient-related discussions of women's health. Students completing the curriculum valued learning women's health, preferred this self-directed learning over lecture, scored highly on knowledge tests, and were involved in more and higher-level discussions of women's health with faculty (P<.001).

CONCLUSIONS

We present a model for the systematic design of a web-based women's health curriculum as part of a medicine clerkship. The web-based instruction resolved barriers associated with limited curriculum time and faculty availability, provided an accessible and standard curriculum, and met the needs of adult learners (with their motivation to learn topics they value and apply this knowledge in their daily work). We hypothesize that our web-based curriculum spurred students to later discuss these topics with faculty. Web-based learning may be particularly suited for women's health because of its multidisciplinary nature and need for vertical integration throughout medical school curricula.

Evaluating and enhancing a women's health curriculum in an internal medicine residency program

OBJECTIVE

Resident education in women's health is required but is often underemphasized. Our aim was to identify women's health topics with the most relevance to our graduates' practices and to determine how well they were prepared to address women's health issues.

DESIGN

Postgraduate survey.

SETTING

University-affiliated internal medicine residency program.

PARTICIPANTS

Program graduates in general internal medicine practice.

METHODS

A survey was drafted listing the 65 topics described in a published residency curriculum in women's health. Respondents indicated the extent to which each item was relevant to their practice and the adequacy of instruction received on a Likert-type scale of 1 (not relevant/inadequate) to 5 (highly relevant/adequate).

RESULTS

The response rate was 86%. Many of the items were highly relevant to our graduates' practices. Learning needs were found in all areas as none of the topics were rated as "adequately" taught during residency. Many areas in the curriculum had low relevance scores. Few differences were seen in the perceived relevance of women's health problems or the adequacy of instruction received based on gender, practice type and setting, or amount of ambulatory training during residency.

CONCLUSIONS

Use of this survey has allowed us to tailor and prioritize learning issues in women's health to meet the needs of our graduates. Increased time in ambulatory rotations alone may not be sufficient to prepare residents to provide comprehensive care in this field. Further study of the effectiveness of a dedicated curriculum in women's heath is needed.

Development of an interdisciplinary women's health training model

In response to expanded residency training requirements in women's health, faculty from internal medicine, obstetrics/gynecology, and psychiatry at Yale University School of Medicine established an interdisciplinary women's health training and education model, the Interdisciplinary Women's Health Clinic (IWHC). The model was one component of a larger, comprehensive women's health program at Yale funded by the Department of Health and Human Services between 1996 and 2000 under the National Centers of Excellence in Women's Health (CoE) designation. This article describes the structure and function of the model, its value to residents and the institution, and its limitations that led to its closure when Department of Health and Human Services support ended. The IWHC was designed as a consultation service that augmented the primary care provided to low-income, minority-group women in an established outpatient primary care setting. An interdisciplinary team of residents and faculty provided and coordinated a range of services for patients and participated in a weekly core curriculum. The model was an important resource to residents and provided high-level integrated care to patients. The combined educational experience helped refine a core interdisciplinary women's health curriculum. Despite these benefits, the IWHC could not be sustained outside the financial and programmatic structure of the larger CoE program. This experience suggests that longitudinal models where residents from different disciplines train in a shared educational and clinical setting may be more durable. Interdisciplinary models are effective ways to train residents and provide integrated care to women. The model's success depends on highly developed collaborative relationships between faculty, nonclinical sources of support, and long-term institutional commitment.

Teaching women's health skills: confidence, attitudes and practice patterns of academic generalist physician

OBJECTIVE

This study assesses the readiness of academic general internists to perform and precept a commonly utilized women's health examination, and procedural and management skills.

DESIGN

Full-time faculty from divisions of general internal medicine and departments of family practice in 9 states reported their encounter frequency with, comfort precepting, and the importance they ascribe to several examination, procedural, and management skills relevant to women's health care; and their attitudes toward performing the pelvic exam and obtaining a Pap smear.

MEASUREMENTS AND MAIN RESULTS

A total of 331 general internal medicine physicians (GIMs) and 271 family medicine physicians (FPs) completed questionnaires, with response rates of 57% and 64%, respectively. More than 90% of GIMs and FPs indicated they were confident precepting the breast and Pap/pelvic examinations. A relatively small percentage of GIMs expressed confidence precepting the management of dysfunctional uterine bleeding (22%), initiating Depo-Provera (21%), and initiating oral contraceptives (45%), while a substantially larger percentage indicated that these skills were important to primary care practice (43%, 44%, and 85%, respectively). Although GIMs indicated they were confident precepting the Pap/pelvic exam, they were less likely than FPs to agree with the following statements: "Performing routine Pap smears is a good use of my time" (GIMs 65%, FPs 84%); "It is a waste of health care dollars for primary care physicians to refer patients to gynecologists for routine Pap/pelvic exams" (GIMs 69%, FPs 90%); "I feel very well trained to do a routine bimanual exam" (GIMs 71%, FPs 98%), and "The clinic where I practice is well equipped to do a Pap smear" (GIMs 78%, FPs 94%).

CONCLUSIONS

Although most academic GIMs are confident precepting the breast and pelvic examination, only a minority are confident precepting the management of dysfunctional uterine bleeding, initiating Depo-Provera, and initiating oral contraceptives. These findings suggest that a number of academic GIMs may not be prepared or willing to perform or precept important women's health skills.

Impact of a veterans affairs continuity clinic on resident competencies in women's health

BACKGROUND

Education in women's health is now considered a core curricular component during residency training in Internal Medicine. There is potential for insufficient training in women's health for residents with a continuity clinic based at a Veterans Affairs (VA) hospital.

OBJECTIVE

To determine the impact of a 3-year continuity clinic based at a VA hospital on residents' self-reported competencies in women's health.

DESIGN

Cross sectional survey using an internal website.

SETTING

University-based residency program in Ann Arbor, Michigan.

MEASUREMENTS AND MAIN RESULTS

Comparison of residents with a VA clinic with residents with non-VA clinics (university and community) in self-reported competencies in knowledge base, counseling, and physical exam skills in the area of women's health. Responses were obtained from 66% (n = 72) of eligible residents. When compared to residents with either a university hospital- or community-based clinic site, VA-based residents reported less confidence in the majority of competencies surveyed. Clinic site had the strongest impact in the knowledge base domain, accounting for between 17% and 33% of the variance in each specific competency. For estimated number of Pap smears and breast exams done in the prior year, VA-based residents reported doing, on average, less than 5 of each per year while non-VA residents reported doing between 11 and 20 of each exam.

CONCLUSIONS

Our data suggest that despite other clinical opportunities in women's health during ambulatory rotations, regular clinical experiences in women's health in the continuity clinic setting are necessary to improve education in this area.

Women's health centers and minority women: addressing barriers to care. The National Centers of Excellence in Women's Health

New models of care delivery have been developed to better coordinate and integrate healthcare for women. In the United States, one of the challenges is to incorporate the needs of racial and ethnic minority populations into these newer care paradigms. This paper begins with a brief historical review of the experience of racial and ethnic minorities in the American healthcare system to provide a context for discussing barriers and limitations of more traditional models of women's healthcare. Specific approaches used by National Centers of Excellence in Women's Health are presented as examples of strategies that may be implemented by other communities to address these barriers.

Resources for teaching about women's health

Given the interdisciplinary quality of women's health, a unique collection of resources is required to provide a practical, evidence-based presentation of the relevant topics. While some students and residents have sought more intensive women's health education from special electives and fellowships, most physicians will not receive their primary instruction about women's health from a specially dedicated course. Therefore, teachers in a broad variety of settings from ambulatory precepting sites to basic science courses will be responsible for planning educational experiences that will integrate women's health issues. This paper provides reviews of 19 teaching tools about women's health ranging from general curricula to books, videos, and CD-ROMs that can be used by educators and learners throughout the continuum of medical education.

Strategies for building a multidisciplinary academic program in women's health

During the decade of the 1990s, women's health has received unprecedented attention from government, industry, marketers of healthcare, and academic medical centers. An assessment of research, education, and healthcare delivery has exposed gaps in our knowledge about gender-related issues. Recognition of gender as a rich frontier for innovation and discovery has resulted in widespread and varied responses and a commensurate increase in activity in the field. However, this diversity of effort has created the new challenge of effectively communicating strategies of response to the multiple disciplines invested in women's health. This article describes a strategy used at Duke University Medical Center to build awareness of women's health through a highly visible and successful Women's Health Seminar Series. The series serves as a focal point for broader efforts to build a comprehensive, multidisciplinary, academic program in women's health with initiatives in clinical care, research, faculty development, provider education, and community outreach.