Medical Education and Leadership in Breastfeeding Medicine

A Foundational Framework for Physician Education in Breastfeeding Medicine

In the United States, the training of physicians starts with premedical education, from kindergarten through undergraduate college (16th grade). During college, various premedical school courses in biology, chemistry, organic chemistry, and physics are required for students who plan to go on to medical school, regardless of their major. To start medical school, applicants must also successfully complete the Medical College Admission Test (MCAT^®). Once in medical school, undergraduate medical education refers to 4 years of study usually divided equally into basic or medical sciences, followed by clinical sciences. In the basic science curricula, students complete coursework in anatomy, physiology, pathology, and many other subjects. The clinical science curricula are traditionally hospital- and practice-based exposures to core specialties such as obstetrics/gynecology, pediatrics, and family medicine, among others.

Throughout medical school, there is a need to integrate breastfeeding education as well as most other clinical topics both vertically and horizontally. Vertical integration from basic science theory to clinical science application is necessary to truly reinforce the foundational concepts learned early on. Horizontal integration across various specialties is also necessary to create well-trained clinicians, regardless of their future specialty choice. To finish medical school and as part of their application for the next stage of training, students must also successfully complete a series of high-stakes examinations administered by the U.S. Medical Licensing Examination (USMLE^®). There is a well-known concept in education that assessment drives learning, which means simply that students will study what is on the test. Having questions about breastfeeding medicine on these high-stakes examinations is therefore one strategy to drive curricular change.

After medical school, graduate medical education includes both residency training to practice as a physician and fellowship training if a subspecialty is desired. Physicians who want to further develop a clinical or academic area of expertise in breastfeeding medicine can complete a fellowship in breastfeeding medicine, women's health, or academic medicine. Some physicians choose to become a Certified Lactation Counselor (CLC) or an International Board-Certified Lactation Consultant (IBCLC). ABM also provides a formal fellowship designation (FABM) for those with advanced knowledge and skills in breastfeeding medicine. ¹

When designing a multifaceted integrated curriculum, both a didactic component and a clinical component must be created. Examples of evidence-based didactic curricula range from the materials created by the American Academy of Pediatrics ² to the ABM 1-day course, “What Every Physician Needs to Know” (WEPNTK), which is offered at the ABM Annual International Conference and in other venues both in the United States and internationally. The clinical portion of breastfeeding education can and should occur in multiple settings where medical students can interact with young families. In the outpatient settings, such as primary care clinics, prenatal clinics, and postnatal visits, trainees can follow patients for both continuity of care and to understand various opportunities and barriers with respect to breastfeeding. In the inpatient setting, trainees can care for expectant mothers in labor and delivery wards as well as postpartum wards. Finally, home visits are an opportunity to follow mothers and babies out of traditional healthcare settings and into their communities.

Noncurricular Opportunities to Create Physician Leaders in Breastfeeding Medicine

While most medical education occurs in a classroom or clinical setting, many opportunities exist in noncurricular settings to create the next generation of physician leaders in breastfeeding medicine. In this paper, we provide a series of examples of medical student engagement in various nonclinical activities.

To start, we provide three examples of opportunities within the framework of teaching and learning. First, Alpert Medical School of Brown University (AMS) offers a preclinical elective to first- and second-year students called “Medical Students Outreach to MotherS-to-be” (MOMS). The course was designed to heighten medical students' awareness of clinical care for pregnant women and their newborns, as well as to provide pregnant patients with a health advocate. Early in the course, the medical students receive a didactic session on breastfeeding; for the clinical component, each student is paired with a pregnant mother and follows the patient(s) prenatally, through delivery, and on to postpartum care. Second, “First Steps” was a program designed by medical students at AMS to teach high school students in Rhode Island about breastfeeding, ideally before their own experiences with pregnancy and childbirth, using the State of New York kindergarten–grade 12 (K-12) curriculum. ³ Third, there are myriad opportunities within interprofessional education (IPE) where physicians can collaborate with lactation counselors, nurses, and pharmacists. As one example, copies of Medications and Mother's Milk were distributed to 47 pharmacies in Rhode Island. A medical student research assistant then surveyed staff at each of these pharmacies and discovered that more than half of the pharmacists never asked women if they were breastfeeding when dispensing medications, thus highlighting an opportunity for more effective IPE. ⁴

We also provide three examples of opportunities within the framework of research to develop physician leaders in breastfeeding medicine, one quantitative, one qualitative, and one procedural. First, a medical student served as a research assistant on a project to perform secondary data set analyses on the National Center for Health Statistics' National Survey of Family Growth regarding birth order and breastfeeding initiation. She performed a literature search, participated in data analysis meetings, and coauthored the article. The study showed that multiparous mothers made the same feeding choice for each of their children more than 70% of the time, highlighting the importance of targeting first-time mothers for both infant nutrition education and breastfeeding support. ⁵ Second, another medical student served as a research assistant on a qualitative project to study, using focus groups, physician-mothers' own experience with breastfeeding. That study showed a gap between breastfeeding recommendations and practices among physicians and offered the student a chance to consider opportunities and potential barriers with respect to her own future parenting. ⁶ Third, several medical students who were already parents themselves coauthored an article on medical student-mothers that is used often by administrators and mentors in health professional schools as a guide to support their female students. ⁷

Next, we provide two examples of opportunities for engaging future physician leaders within the framework of advocacy. Advocacy in the workplace, educational settings, and through legislation are prime opportunities to promote breastfeeding education. First, ABM developed a formal statement entitled “Breastfeeding Support for Mothers in Workplace Employment or Out of the Home Educational Settings” that was created, in part, with support from medical students. ⁸ Second, legislation in Rhode Island has provided support for nursing working mothers and breastfeeding in public places. In 2003, state legislators cocoordinated a group of healthcare professionals that included medical students to facilitate the successful passage of legislation, which requires employers to provide a private, secure, and sanitary place for an employee to breastfeed her child or express breast milk during the workday (Nursing Working Mothers: Rhode Island H 5507/S 151). Similarly, in 2008, the same group, but that year with different students, facilitated the successful passage of legislation that states that a mother may breastfeed her child in any place open to the public (Breastfeeding in Public Places: Rhode Island H 7467/S 2283).

Last, coordinated personal and professional development of medical trainees is paramount when promoting breastfeeding and creating physician leaders. In general, women in medicine groups often address childbirth and parenting issues among colleagues. More specifically, MomDocFamily and Mama, MD are examples of a professional network and a website, respectively, which specifically target female medical students and physicians who are parents.^9,10 These resources address the challenges of pregnancy, breastfeeding, and parenting during medical training and beyond.

A Case Study

Esther Bell is a senior student in her final year of medical school at American University of the Caribbean School of Medicine (AUC). She is one of five siblings, a first-generation American of Nicaraguan heritage, and a first-generation college student who attended the University of Florida where she majored in Health Education and Behavior. After earning a bachelor's degree, Esther pursued a master's in the same field before working for 2 years as a Senior Health Educator for the Florida Department of Health in Miami Dade County. These educational and work experiences solidified her interest in becoming a physician.

Esther is in her final year of clinical training at AUC, a 4-year international medical school with more than 6,500 graduates in the United States and abroad. Founded in 1978, the university is one of the oldest medical schools in the Caribbean and has a strong history of preparing globally minded physicians who enter primary care—many in underserved communities or healthcare professional shortage areas. The first five semesters of medical school take place at the university's medical sciences campus located in Sint Maarten. During the second half of medical school, students rotate at various clinical locations in the United States and United Kingdom for their core clerkship rotations and electives.

Esther's medical sciences curriculum addressed breastfeeding in a deliberately integrated manner. In Immunology, students learned of the immune benefits and the transference of immunoglobulins from mother to baby through breast milk. In Anatomy, they learned the anatomy of the female breast and the way it is structurally formed to produce, store, and dispense breast milk for infants. In Physiology, students learned about the production of breast milk and how the human body uses various hormones and signals to let down breast milk to a suckling infant. In Pathology, they not only learned of conditions associated with breastfeeding such as mastitis but they also learned of the various pathologies that breastfeeding protects against. And in Behavioral Sciences, they learned about the bonding experience between mother and baby and the long-term psychological benefits for both.

Outside of the classroom, Esther also participated in multiple community service opportunities in Sint Maarten, held an executive position in the Latin Medical Student Association, completed a medical mission trip to Guatemala, and was President of the medical school's Student Government Association.

After her formal transition from medical sciences to clinical sciences, Esther did her core clerkship rotations in obstetrics and gynecology and pediatrics at a community hospital in the United Kingdom where she was trained by midwives and learned a holistic approach to maternal–child health. She then returned to the United States for her final year of medical school where she has participated in a variety of pediatric electives in New York. Esther has completed one elective in a neonatal intensive care unit at a tertiary care center, where she learned about breast milk banks, and another elective at a community hospital where she engaged with teams of healthcare providers managing health supervision visits in the community.

The future Dr. Bell is preparing for a career in pediatrics in the United States where, as a globally trained physician, she plans to serve as a breastfeeding and maternal–child health advocate and changemaker throughout her career. Esther's participation in the ABM 9th Annual Summit in Washington, DC, was an experience she describes as impactful and inspiring, both for her and for several other attendees who have since become her mentors.

Conclusion

Around the world, the exposure of physicians to breastfeeding education during their training is still truly varied, even with the ABM now more than 20 years old and with members in 58 countries. In this study, we have provided an overview of the current training system for physicians who practice medicine in the United States. We offer several recommendations and ideas for all health profession educators, including (1) strategies to systematically integrate breastfeeding medicine into both the required curriculum, horizontally and vertically, and the assessment process, as well as (2) opportunities to engage and inspire learners in all aspects of breastfeeding medicine such as teaching, research, advocacy, and professional development. We conclude by showcasing the personal and professional experiences of one internationally trained future pediatrician.