Womenʼs Health Education

Figure: Janet B. Henrich, MDIn the 1990s, a unique convergence of scientific, political, social, and market forces led to the emergence of women's health as a distinct field of scientific inquiry. The rise of women's health as a field unto itself has had important implications for clinical practice and for the education and training of physicians. Advances in scientific knowledge related to women's health and to sex and gender differences have added to our understanding of the disorders that cause the greatest morbidity and mortality in women. These advances were driven in part by congressional legislation that expanded research on women's health through the National Institutes of Health.1 At the same time, women as health care consumers have been poised politically and financially to adopt and to advocate this new field, while the rapid proliferation of managed care in the United States has added a new market-driven dimension to the concept of women's health. Within academic institutions, however, there has been uncertainty about what actually constitutes the field of women's health and what the best ways are to integrate the new medical information and concepts into graduate medical education and clinical practice. Given the uncertainty surrounding this new field, and the potentially competing nature of the forces that created it, how have efforts to integrate women's health education and training into medical schools and residency training programs fared? What has been accomplished, what has been learned in the process, and what remains to be done? RECENT CHANGES IN WOMEN'S HEALTH EDUCATION The first major policy-making organization to comprehensively address women's health education and training was the Council on Graduate Medical Education (COGME), the federally mandated body charged with providing recommendations to the U.S. Congress on physician education and training in the United States. In its 1995 report, Women and Medicine: Physician Education in Women's Health and Women in the Physician Workforce,2 COGME provided the rationale for examining unique aspects of women's health beyond the traditional focus on reproductive organs and function. COGME's new paradigm for women's health emphasized the important influence of sex-specific biological mechanisms and psychosocial factors on health and disease. It addressed the implications of this new model for physician education and outlined the steps necessary to incorporate these concepts into graduate medical education through curricular change and the broader development of academic programs in women's health. To facilitate these changes, COGME suggested actions by academic institutions, professional organizations, and government agencies that would help ensure that physicians-in-training, regardless of their career interests, acquire the knowledge and skills requisite to providing comprehensive care to women. In the five years since the COGME report was published, many of its recommendations have been implemented. At academic health centers, residency programs in the disciplines that are the basis of most of the primary care to women have been expanded to address new national residency training requirements in comprehensive health care for women. Furthermore, 11 academic centers now offer selective residency programs in women's health, and 18 sponsor women's health fellowships.3 Nationally, increased collaboration between major professional organizations has resulted in new educational programs that address women's health across a range of learning levels. To inform curricular change, COGME also recommended that academic health centers evaluate the knowledge base within each of the basic and clinical science disciplines to determine what is being taught concerning sex and gender issues and how new information is incorporated. Coincident with the COGME report, the American Association of Medical Colleges, in collaboration with the National Institutes of Health's Office of Research on Women's Health and other government agencies, conducted a national survey of the 126 allopathic medical schools in the United States to assess the integration of women's health and gender content into medical school education. Eighty five schools (67%) responded. The findings of the 1996 report4 remain the most comprehensive assessment to date on this subject. First, the results showed wide variation among schools in the numbers of women's health topics included in the curricula. Although more than 50% of the schools that responded to the survey reported that they taught at least 90% of the topics listed in the survey, the proportions of topics taught ranged from 30% to 100%. Most schools included information on sexual and reproductive function, medical interviewing and examination skills, and diagnostic tests specific to women. Fewer schools incorporated sex-specific information about heart disease, lung cancer, and stroke—the leading causes of death in women—or chronic medical disorders that disproportionately affect women, such as temporomandibular joint disease, chronic fatigue, interstitial cystitis, and fibromyalgia. At the time of the survey, only nine schools reported having an office or program responsible for coordinating and monitoring the integration of women's health and gender-related issues into the curriculum. This year, another survey showed that this number had increased to 41.5 Equally important, the 1996 report provided guidelines for schools interested in further integrating women's health and gender-relevant information into their curricula. These strategies included the development of case-based learning, of a life-span approach, of interdisciplinary clinical teaching sites, and of mechanisms to assist faculty in increasing their competence in women's health. To implement these changes, it was recognized that women's health must have a form and a structure, a source of funding, and a recognized place in academic institutions. Many of these objectives could be achieved by the establishment of collaborative interdisciplinary centers or programs in women's health within academic health centers. The Department of Health and Human Services, through the Public Health Service Office on Women's Health, funded six such vanguard centers in 1996, another six in 1997, and an additional six in 1998. These 18 National Centers of Excellence in Women's Health have facilitated the development of innovative clinical models, integrated curricula, interdisciplinary research on women's health, and the development of women faculty. Of the 41 schools in 1998 with an office or program dedicated to integrating women's health into the curricula, 13 were designated Centers of Excellence. The impact of the Centers on curricular reform at their respective institutions is currently being evaluated. At the first centers of Excellence in Women's Health National Forum, held in late 1999,6 representatives from the Centers described some of their early experiences in developing curricula, creating strategies for incorporating women's health into training programs, and identifying funding to support educational initiatives. Examples included computer-based methods to create on-line teaching programs and resources, the use of objective structured clinical examinations and standardized patients, and the creation of interdisciplinary clinical training sites. Everyone stressed the importance of senior administrative leadership and the key role of students in initiating change. THE CHALLENGE CONTINUES Despite these impressive advances in integrating women's health and gender content into graduate medical education, significant barriers remain. At academic institutions, traditional tensions between disciplines over teaching time, reimbursement for teaching activities, course content, and course directorship can hinder the development of interdisciplinary women's health initiatives. The pressure for curricular reform occurs at a time when most academic medical centers are struggling with financial losses related to changes in reimbursement, particularly for training activities. In this environment, support for innovative educational programs can be difficult to secure and sustain. Furthermore, the establishment of interdisciplinary clinical training sites has been hampered by market forces that reimburse poorly for highly cognitive and integrated services, the sine qua non of women's health care. And faculty who face increasing demands as they climb the academic ladder may find the risks inherent in interdisciplinary work too great. Regardless of these challenges, the impetus for change continues at all levels. Growing scientific information about women's health disorders and the significance of sex and gender differences has important implications for the health of both women and men; the need continues to apply this new knowledge in physicians' education and clinical practice. Growing numbers of women entering the health professions will continue to seek out this information and should prove to be the driving force in bringing about ongoing change. As health care consumers, women will also continue to advocate comprehensive, integrated clinical services that extend beyond the organ-specific preventive health measures currently covered by managed care organizations.