It Takes a Village: An Interdisciplinary Approach to Preparing Internal Medicine Residents to Care for Patients at the Intersection of Women's Health, Gender-Affirming Care, and Health Disparities

Objective: To create an interdisciplinary curriculum to teach key topics at the intersection of women's health, gender-affirming care, and health disparities to internal medicine (IM) residents. Materials and Methods: A core team of faculty from IM, Obstetrics and Gynecology, and Surgery partnered with faculty and fellows from other disciplines and with community experts to design and deliver the curriculum. The resulting curriculum consisted of themed half-day modules, each consisting of three to four inter-related topics, updated and repeated on an ∼3-year cycle. Health equity was a focus of all topics. Module delivery used diverse interactive learning strategies. Modules have been presented to ∼175 residents annually, beginning in 2015. To assess the curriculum, we used formative evaluation methods, using primarily anonymous, electronic surveys, and collected quantitative and qualitative data. Most surveys assessed resident learning by quantifying residents' self-reported comfort with skills taught in the module pre- and postsession. Results: Of 131 residents who completed an evaluation in 2022/23, 121 (90%) "somewhat" or "strongly" agreed with their readiness to perform a range of skills taught in the module. In all previous years where pre- and postsurveys were used to evaluate modules, we observed a consistent meaningful increase in the proportion of residents reporting high levels of comfort with the material. Residents particularly valued interactive teaching methods, and direct learning from community members and peers. Conclusion: Our interdisciplinary curriculum was feasible, valued by trainees, and increased resident learning. The curriculum provides a template to address equity issues across a spectrum of women's and gender-affirming care conditions that can be used by other institutions in implementing similar curricula.

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.

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.

Medical students' assessment of education and training in women's health and in sex and gender differences

BACKGROUND

The authors surveyed U.S. medical students to learn their perceptions of the adequacy of women's health and sex/gender-specific teaching and of their preparedness to care for female patients.

METHODS

Between September 2004 and June 2005, third and fourth year students at the 125 allopathic medical schools received an online survey conducted by the American Medical Women's Association (AMWA). Students rated the extent to which 44 topics were included in curricula from 1 to 4 (1 = no coverage, 4 = in-depth coverage) and their preparedness to perform 27 clinical skills (1 = no preparation, 4 = thorough preparation).

RESULTS

From 101 of the 125 schools, 1267 students responded (mean number of respondents/school = 13, SD 12). The mean curriculum rating (2.53, SD 0.52) indicated brief to moderate coverage of topics. The mean preparedness rating was higher (3.09, SD 0.44), indicating moderate preparedness. In a regression model, female student sex and site of an AMWA chapter were associated with lower mean combined curriculum and preparedness ratings (female 2.76, male 3.01, p < 0.001; AMWA 2.77, non-AMWA 2.89, p < 0.001), whereas other school characteristics (female dean, federally funded women's health program, and proportion of tenured women faculty) had no association.

Limitations of follicle-stimulating hormone in assessing menopause status: findings from the National Health and Nutrition Examination Survey (NHANES 1999-2000)*

OBJECTIVE

We used data from the National Health and Nutrition Examination Survey (NHANES 1999-2000) to: establish new population-based estimates for follicle-stimulating hormone (FSH) and luteinizing hormone (LH); identify factors associated with FSH; and assess its efficacy in distinguishing among women in the reproductive, menopause transition, and postmenopausal stages.

DESIGN

Nationally representative sample of 576 women aged 35 to 60 years examined during NHANES 1999-2000.

RESULTS

Levels of FSH and LH increased significantly with reproductive stage. (Geometric mean FSH levels for successive stages: reproductive, 7.0 mIU/mL, SE 0.4; menopause transition, 21.9 mIU/mL, SE 3.7; and postmenopause, 45.7 mIU/mL, SE 4.3). There was considerable overlap, however, among distributions of FSH by stage. Only age and reproductive stage were significantly associated with FSH in multivariable analysis. FSH cutoff points between the reproductive and menopause transition stages [FSH = 13 mIU/mL, sensitivity 67.4% (95% CI 50.0-81.1), specificity 88.1% (95% CI 81.1-92.8)] and between the menopause transition and postmenopause stages [FSH = 45 mIU/mL, sensitivity 73.6% (95% CI 60.1-83.7), specificity 70.6% (95% CI 52.4-84.0)] were neither sensitive nor very specific.

CONCLUSIONS

Age and reproductive stage are the most important determinants of FSH levels in US women; however, FSH by itself has limited utility in distinguishing among women in different reproductive stages.

What do medical schools teach about women's health and gender differences?

PURPOSE

To examine the curricula of U.S. medical schools to assess the inclusion of women's health and gender-specific information and identify institutional characteristics associated with this content.

METHOD

Using data from the Association of American Medical Colleges' Curriculum Management and Information Tool (CurrMIT), in November 2003 to February 2004 the authors performed a curriculum search of schools that entered course/clerkships in CurrMIT to identify interdisciplinary women's health or gender-specific courses/clerkships. A subset of schools that entered comprehensive information in CurrMIT was searched for a specified list of women's health topics and or gender-specific content on any topic. Statistical analyses were performed to assess the relationship between frequency of topics and school characteristics.

RESULTS

The authors identified 95 schools that entered related courses/clerkships. Ten courses/clerkships at nine schools met criteria for an interdisciplinary women's health course/clerkship. In the subset of 60 schools with comprehensive CurrMIT information, 18 specified women's health topics were identified, as well as 24 topics on gender-specific content, for a total of 42 topics. The number of topics taught ranged from zero to 26 (mean = 11). More than 50% of these schools taught 11 of the 18 specified topics, while fewer than 30% included gender-specific topics. There was no association in bivariate analysis between the mean number of topics taught and schools' characteristics; however, a women's health program (p= .01) and female dean (p= .06) were positively associated in a regression model.

CONCLUSIONS

Few schools offer interdisciplinary women's health courses/clerkships or include gender-specific information in their curricula. A designated women's health program may increase this content in schools' curricula.

Women's health education initiatives: why have they stalled?

Since the U.S. Congress first requested an assessment of women's health content in medical school curricula ten years ago, surveys indicate at least a two-fold increase in the number of schools with a women's health curriculum and no change in the number that offer a women's health clinical elective or rotation. Despite a marked increase in the number of schools with an office or program responsible for integration of women's health and gender-specific content into curricula, change has been modest. Reasons for this slow progress include uncertainty about the domain of women's health and what should be included in a curriculum, a lack of practical guidelines for implementation, and institutional resistance to change. The dominant factors that will influence future curriculum development are the increasing scientific knowledge base on sex and gender differences and the emerging scientific field of sex-based biology, both of which have potential to benefit the health of women. Evidence-based data on significant sex and gender differences will provide compelling reasons for schools to integrate this information into curricula, and new educational initiatives must further develop educational models to help implement change. As women's health becomes synonymous with the term "sex and gender differences," the challenge to schools is to address equally in their curricula those unique aspects of women's health that were part of the original intent of the congressional mandate.

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.

Postmenopausal estrogen replacement therapy is associated with adverse breast cancer prognostic indices

Previous studies have reported that breast cancer patients who used estrogen replacement therapy (ERT) have more favorable tumor characteristics and decreased mortality compared with nonusers. However, these findings may be due partly to increased medical surveillance in ERT users and detection of early stage tumors. Postmenopausal women with biopsy-proven breast cancer (n = 108) were identified based on their participation in screening mammography. Based on self-administered questionnaires completed at the time of mammography, 29 of these were users of ERT. Tumor characteristics (histology size, nodal status, and estrogen receptor content) of ERT users were compared with those of nonusers. After adjusting for potentially confounding variables, the odds ratios (OR) describing the relationship between ERT use and the risk of invasive histopathology (OR = 1.35, 95% CI = 0.48, 3.75), positive nodes (OR = 2.43, 95% CI = 0.59, 10.10), size > or = 2.0 cm (OR = 2.34, CI = 0.66, 8.27), or negative estrogen receptor status (OR = 1.08, 95% CI = 0.18, 9.38) were > 1, although none reached statistical significance. When the subjects were separated into two prognostic groups based on the presence or absence of adverse prognostic indices, ERT users had a statistically significantly increased risk of being in the poor prognostic group (tumor size > or = 2.0 cm or positive nodes or negative estrogen receptor content) (OR = 4.48, 95% CI = 1.10, 18.30). The risk was highest in current users (OR = 6.28, 95% CI = 1.16, 34.00), users for 5 or more years (OR = 7.77, 95% CI = 1.09, 55.60), and users of nonconjugated estrogen (OR = 9.63, 95% CI = 1.18, 78.60). Although our sample size is small and we do not currently have information on long-term outcomes, the findings from this screening population suggest that ERT may have an adverse effect on important breast cancer prognostic indices.

Postmenopausal estrogen use and invasive versus in situ breast cancer risk

To examine the effect of cancer histopathology on the relationship between estrogen-replacement therapy (ERT) use and breast cancer risk, we performed a case-control study of 109 postmenopausal women 45 years or older with in situ or invasive breast cancer matched to 545 controls. When in situ and invasive tumors were combined, the overall odds ratio (OR) describing the association between ERT use and breast cancer risk was not statistically significantly elevated (adjusted OR = 1.48, 95% confidence interval [CI] = 0.89-2.47). When the analyses were confined to women with invasive disease, risk estimates were uniformly higher (adjusted OR = 1.85, 95% CI = 1.00-3.45). In contrast, the overall estimate for the relationship between ERT use and in situ breast cancer was close to 1 (adjusted OR = 1.08, 95% CI = 0.42-2.77). The positive association between ERT use and invasive breast cancer we observed, and the lack of association in women with in situ disease, may represent a distinct biological difference or may be related to the small sample size of our study.

The postmenopausal estrogen/breast cancer controversy

OBJECTIVE

To provide an overview of the postmenopausal estrogen/breast cancer controversy emphasizing the sources of disagreement in the literature and their clinical and research implications.

DATA SOURCE AND SELECTION

A MEDLINE search of the English-language literature and a review of bibliographies of meta-analyses describing the association between postmenopausal estrogen use and breast cancer risk.

DATA EXTRACTION

Twenty-four original articles and three meta-analyses were reviewed. In addition, five studies that attempted to minimize detection bias were reviewed to assess the potential role of this bias on risk estimates.

DATA SYNTHESIS

Among the original articles, risk estimates ranged from a protective to an adverse effect in women who ever used estrogens; no consistent quantitative effects of estrogens on breast cancer risk were found. In the meta-analyses, summary risk estimates were not significantly elevated in women who ever used estrogen. Findings from European-based studies may account for the increased risk associated with increasing duration of use reported in one meta-analysis. In studies that controlled for detection bias, risk estimates were 1 or less in the ever-used category; there was no consistent effect across other categories of use.

CONCLUSION

These findings do not support an overall increased risk of breast cancer in women who ever used postmenopausal estrogens or a conclusive or consistent effect across other measures of use. Cross-national differences in estrogen use and inequalities in breast cancer detection between estrogen users and nonusers may account for the increased risk estimates reported in some studies. Newer estrogen and progestin-opposed regimens need to be evaluated further.

Integrating general medicine and rheumatology training in the outpatient setting: a practice model

The authors describe a primary care-based educational and practice model that integrates general medicine resident education in outpatient rheumatology with specialty fellowship training. Compared with the use of traditional specialty clinics, the model provides better access and service to patients and more appropriate training for residents. Revenues from clinical service delivered by faculty-supervised residents and fellows support 80% of the operating costs and educational activities of the model. The conceptual framework for the model reconciles the educational goals and practice philosophies of general medicine and specialty training and is applicable to training in other predominantly outpatient specialty areas.

The contributions of individual factors to thromboembolic stroke

To determine the importance of individual factors to thromboembolic stroke (TES) risk, the authors performed a hospital-based case-control study. Ninety cases (56 men and 34 women, ages 15 to 65) discharged from the hospital between January 1981 and December 1984 with a diagnosis of TES supported by computed tomography were matched to 174 control patients (106 men and 68 women). Data on potential risk factors were obtained from the medical record and telephone interview. Using multivariate analysis, three variables were significantly associated with TES risk: hypertension (odds ratio [OR] = 3.4; 95% confidence interval [CI] 1.9-6.0), diabetes (OR = 4.0; 95% CI 2.0-8.3), and smoking (OR = 2.0; 95% CI 1.2-3.6). The data were also analyzed using a direct risk assessment method. This analysis describes the risk in patients with any one factor compared with patients without any of the factors. The direct estimates of risk increased by 71% for hypertension (OR = 5.8), 28% for diabetes (OR = 5.1), and 90% for smoking (OR = 3.8). The authors conclude that hypertension, diabetes, and smoking are the major risk factors for TES in patients 65 years old or younger.

A controlled study of ischemic stroke risk in migraine patients

To help resolve the uncertain relationship between migraine headache and ischemic stoke, we performed a hospital-based, case-control study. Eighty-nine cases ages 15-65 with a head computed tomography (CT) scan supported diagnosis of ischemic stroke were matched to 178 control subjects. Using information obtained by telephone interview, the patients were placed into three categories according to explicit criteria: classic migraine; common migraine; and no migraine headache. Overall, the association between migraine and ischemic stroke is significantly increased only in patients with classic migraine [odds ratio (OR) = 2.6, 95% confidence interval (CI) 1.1-6.6]. In addition, classic migraine does not appear to increase ischemic stroke when hypertension, diabetes or smoking are present; however, when these other risk factors are absent, classic migraine is strongly and significantly associated with the risk of ischemic stroke [no hypertension, OR = 5.7 (95% CI 1.6-20.2); no diabetes, OR = 3.4 (95% CI 1.2-9.3); non-smoker OR = 4.3 (95% CI 1.2-15.0)]. Since none of the migraine patients in our study had a migrainous stroke, an underlying disorder other than prolonged vasospasm may be responsible for the observed increased risk. Our data suggest that classic migraine may be a marker for patients at increased risk for ischemic stroke unrelated to a migraine attack.

The association between migraine and cerebral vascular events: an analytical review

This paper explores the uncertain relationship between migraine headache and thromboembolic stroke. In reviewing the literature that links migraine with thromboembolic cerebral vascular events, a distinction is made between two stroke events that occur in migraine patients: stroke associated with a migraine attack (a migrainous stroke) and stroke unrelated to a migraine attack (a non-migrainous stroke). In a recent community-based stroke register, migrainous strokes occurred at a rate of 3.4 per 100,000 per annum. Prevalence rates for migraine in young stroke populations (11-28%) are similar to those in the general population and do not support an additional long-term risk of non-migrainous stroke in migraine patients. The only study providing a controlled estimate of long-term thromboembolic stroke risk (odds ratio = 1.7; 95% CI 1.3, 2.2) included only women and has not been independently confirmed. The contribution of migraine to other known risk factors for thromboembolic stroke needs to be examined further by controlled studies.

Stroke and migraine in the Oxfordshire Community Stroke Project

A total of 323 cases of first-ever stroke were registered in the first 2 years of the Oxfordshire Community Stroke Project. Of these patients, 244 (76%) had a stroke due to cerebral infarction. There was a past history of migraine headaches in 56 (17%) of the 323 cases of stroke and in 44 (18%) of the 244 cases of cerebral infarction. A past history of migraine headaches was no commoner in patients with stroke due to cerebral infarction than in those with stroke due to intracranial haemorrhage. One hundred and seventy-three (71%) patients with cerebral infarction had at least one risk factor for ischaemic stroke; the frequency of such risk factors was similar in patients with and without a history of migraine. In 7 (3%) of the 244 patients the cerebral infarction was presumed to be "migrainous"; however, only 3 of these 7 (1.2% of the 24) were free of risk factors for ischaemic stroke. If all 7 cases were considered migrainous, the incidence rate of first migrainous cerebral infarction was 3.36 per 100,000 per year (95% confidence limits 0.87-5.86). If only the 3 patients who were free of risk factors were included, the incidence was 1.44 per 100,000 per year (95% confidence limits 0-3.07).