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

Abstract

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.

Introduction

Women currently make up 50.8% of the United States population.¹ By 2020, national demand for women's health care is expected to grow by 6% compared with 2013.² Despite this increased demand, women's health has been underrepresented in medical education and specifically, internal medicine (IM) training.³ In 1997, in response to a national effort to promote women's health, the American Board of Internal Medicine (ABIM) published a report outlining a list of core competencies in women's health and recommendations for training internists.³ The Accreditation Council for Graduate Medical Education (ACGME) also listed “gender-specific diseases” as a graduation requirement for IM residency.⁴

Other national organizations, such as the American College of Physicians, the National Academy on Women's Health Medical Education, and the Council on Graduate Medical Education, were also involved in efforts to promote greater focus on women's health in medical education.³ Furthermore, in 2013, the U.S. Department of Health and Human Services (HHS), Health Resources and Services Administration (HRSA), and Office of Women's Health (OWH) published a report with the goal of encouraging interdisciplinary collaboration in women's health education across different health professions.⁵

Despite these national efforts to improve women's health education, IM providers remain unprepared to provide comprehensive care to women.^6,7 Multiple studies surveying IM residents have shown that trainees report low comfort levels in women's health topics, including preconception counseling, contraception, abnormal uterine bleeding, and urinary incontinence.^8

–11 Similarly, surveys of IM program directors have not shown a significant increase in women's health education opportunities over time, despite efforts to improve women's health in graduate medical education over the past two decades.^12,13 Although IM program directors agree that residents need to master topics in women's health, a survey of IM program directors published in 2017 revealed that educational opportunities in women's health remain limited.¹³

To complicate this effort further, there are not clear guidelines for what constitutes “women's health” content. The ABIM's core competencies list broad domains, such as “sex and gender-related biology differences,” “common gynecologic disorders,” and “cancer screening and principles of management,” without specifying exact conditions.³ ACGME requirements state that residents are expected to manage patients with “gender-specific diseases,” but does not provide explicit content areas for women's health.⁴ To address this issue, Farkas et al. published a list of 35 core topics in women's health for IM residents, derived by consensus from women's health experts across the country.⁶

Given these apparent deficiencies in women's health education, we sought to evaluate the landscape of women's health curricula in IM residency training programs. The objective of this review was to describe an overview of published women's health curricula in IM residency programs. We aimed to subsequently identify potential areas for improvement to inform future advancements in women's health education.

Materials and Methods

Search strategy

The search strategy was prepared by an informationist (C.C.N.) in cooperation with the coauthors. The search strategy design was based on input from the authors. Iterative searches were conducted in November 2017, February 2018, and June 2018 using the following databases: PubMed; Embase (Embase.com); Cochrane Library (cochranelibrary.com); Scopus; ERIC (Education Resources Information Center, EBSCO); Web of Science; and MedEdPORTAL (mededportal.org). Search strategies for all databases were adapted from the PubMed search strategy. Database searches were limited to the last 20 years of publication (1998–2018) and no language limitations were applied. Search terms included women's health conditions (as defined by the term “women's health” as well as the expert consensus list of women's health topics published by Farkas et al.),⁶ medical education, and curriculum development and evaluation. A list of search strategies can be found in the Appendix Table A1. The references of all included full-text articles were also hand-searched by the first author (C.M.Z.) to identify any sources missed by the automated search.

Inclusion and exclusion criteria

Articles were included if they (1) addressed women's health topics (as determined by the term “women's health” or per women's health topics listed by Farkas et al.),⁶ (2) described a curriculum, defined by the authors as including a description of formal educational strategies and evaluation methods and/or results (3) were designed for IM residents (either alone or in conjunction with other specialties), (4) based in North America, and (5) were published between 1998 and 2018. For this review, we excluded women's health curricula designed for medical students, fellows, or attending physicians. Lesbian, gay, bisexual, and transgender (LGBT) curricula were excluded as well.

Study selection and data collection

Titles and abstracts were screened independently by two reviewers to identify studies related to women's health curricula for IM residents. Specifically, all titles and abstracts were reviewed by one author (C.M.Z.). Authors R.B.L. and E.R.I. each reviewed half of the titles and abstracts. Similarly, all full-text articles were reviewed by two authors according to the inclusion criteria as discussed above. One author (C.M.Z.) reviewed all of the full-text articles. Authors R.B.L. and E.R.I. subsequently each reviewed half of the full-text articles. Conflicts that arose in both stages were resolved through consensus (C.M.Z., R.B.L., and E.R.I.).

Data abstraction

Data were abstracted from each full-text article that met inclusion criteria and entered into a spreadsheet. One author (C.M.Z.) abstracted data from all of the included articles. Authors R.B.L. and E.R.I. each abstracted data from half of the included articles. Data abstracted included first author's name, journal, year of publication, setting, learner population, learner level, number of learners, women's health topics covered, duration of curriculum, learning objectives, educational methods, learner assessment, program evaluation, and study quality using the Medical Education Research Study Quality Instrument (MERSQI).¹⁴ Conflicts were resolved through author consensus (C.M.Z., R.B.L., and E.R.I.).

Assessment of quality

We determined quality using the MERSQI score, developed by Reed et al.,¹⁴ to grade the quality of medical education studies. The MERSQI score assesses the following domains: study design, sampling, type of data, validity of evaluation instrument, data analysis, and outcomes, and is scored from a range of 5 (lowest quality) to 18 (highest quality). The MERSQI has been used broadly as a measure of educational scholarship quality.^14,15

Data synthesis and analysis

Descriptive analysis was used to compare abstracted data.

Results

The search yielded 1004 unique sources. The selection process is shown in Figure 1. Nine hundred sixty-four sources were removed based on the inclusion and exclusion criteria. The full texts of 45 articles (including 5 articles identified via hand searching) were reviewed. Sixteen articles describing unique women's health curricula met the inclusion criteria.^{16

–31} Twelve of the 16 articles (75%) were published before 2010.^{16,18

–21,23,24,26,27,29
–31} Five curricula included IM and other medical specialties,^{19,21,22,27,30} whereas the remaining curricula were created for IM residents only.^{16
–18,20,23

–26,28,29,31} Only one curriculum included learners from other health professions beyond medicine.²⁷ The 16 articles are summarized in Table 1.

FIG. 1.

Modified preferred reporting items for systematic reviews and meta-analyses (PRISMA)* flow diagram: identification of included articles in scoping review. *Diagram obtained and modified from: Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group (2009). Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. PLOS Medicine 6(6): e1000097. **Databases searched: PubMed = 441, Embase = 536, Scopus = 413, Cochrane Library = 23, ERIC = 12, Web of Science = 129, MedEdPORTAL = 2. ERIC, Education Resources Information Center.

Table 1.

Summary of Studies Reporting on Women's Health Curricula in Internal Medicine Residency Programs

Author	Publication year	Specialty	No. of IM learners	IM learner level	No. of WH topics
Brienza et al.¹⁶	2005	IM	36	PGY 1–3	1
Ceylony et al.¹⁷	2017	IM	47	PGY 2–3	>2
Conigliaro et al.¹⁸	2007	IM	35	PGY 1–3	>2
Freda et al.¹⁹	2002	IM, FM, OB/GYN, pediatrics	171	Not reported	1
Haskell and Reisman²⁰	2004	IM	28	PGY 1–3	1
Henrich et al.²¹	2003	IM, OB/GYN, psychiatry	Not reported	PGY 2–3	>2
Jiang et al.²²	2012	IM, FM, OB/GYN	74	PGY 1–2	>2
Korenstein et al.²³	2003	IM	101	PGY 2	>2
Kripke et al.²⁴	1998	IM	55	Not reported	1
Loeb et al.²⁵	2010	IM	25	PGY 2–3	1
Powrie et al.²⁶	2000	IM	Not reported	Not reported	>2
Rosen et al.²⁷	2006	IM, FM, OB/GYN, psychiatry, urology, geriatrics, pediatrics, public health	46	Not reported	1
Singh et al.²⁸	2010	IM	63	PGY 2–3	>2
Spagnoletti et al.²⁹	2008	IM	68	PGY 2–3	>2
Spencer and McNeil³⁰	2002	IM, OB/GYN	65	PGY 2–3	>2
Watkins and Moran³¹	2004	IM	23	PGY 1–2	1

IM, internal medicine; FM, family medicine; OB/GYN, obstetrics and gynecology; PGY, postgraduate year; WH, women's health.

Content

Content varied among the different studies. Six curricula addressed a single women's health topic,^{16,19,24,25,27,31} while nine studies described curricula focused on two or more women's health topics.^{17,18,21
–23,26,28
–30} The most common topics included: intimate partner violence (31%), menopause (31%), abnormal uterine bleeding (25%), breast and cervical cancer screening (25%), and osteoporosis (25%). Only two curricula addressed procedural skills.^17,31 Three curricula discussed topics not included on our list of women's health topics, including depression,²⁸ thyroid disorders,³⁰ and diabetes.³⁰ The curriculum created by Haskell and Reisman focused on increasing exposure to women and women's health topics in a Veterans Affairs (VA) clinic setting and did not detail specific content areas.²⁰ The women's health topics are summarized in Figure 2.

FIG. 2.

Frequency of women's health topics in included studies.

Educational settings and methods

Twelve of 16 women's health curricula (75%) were implemented in the outpatient setting.^{16
–18,20

–25,28,30,31} Three curricula were targeted at increasing exposure to women for residents who see patients in VA ambulatory clinics.^17,18,20 One curriculum was delivered during an inpatient consultation service,²⁶ and one curriculum was delivered via online modules.²⁹ Two curricula did not specify the setting.^19,27 The duration of curricula ranged from 1-day workshops (25%)^16,24,27,31 to longitudinal curricula spanning 3 years of residency as a part of continuity clinic (13%).^18,20 Most commonly, curricula were given over a month-long period (38%).^{17,21
–23,26,28} Table 2 illustrates the various settings and teaching methods used. Eleven curricula used more than one teaching method.^{16,17,21

–28,31} Of the teaching methods used, didactics were most common (69%).^{16,19,21

–28,31} The least common teaching method was online modules (6%).²⁹ Table 3 shows the frequency of each teaching method.

Table 2.

Summary of Setting, Duration, and Educational Methods

Author	Setting	Duration	Educational method
Brienza et al.¹⁶	Ambulatory	1 Day workshop	Didactics Small group sessions Video teaching resources Role play Homeless shelter visit
Ceylony et al.¹⁷	Ambulatory	1 Month	In-clinic teaching Written materials Procedural training/hands-on skills
Conigliaro et al.¹⁸	Ambulatory	Longitudinal (continuity clinic)	In-clinic teaching
Freda et al.¹⁹	Not stated	1 Week	Didactics
Haskell and Reisman²⁰	Ambulatory	Longitudinal (continuity clinic)	In-clinic teaching
Henrich et al.²¹	Ambulatory	1 Month	Didactics In-clinic teaching Written materials
Jiang et al.²²	Ambulatory	1 Month	Didactics In-clinic teaching
Korenstein et al.²³	Ambulatory	1 Month	Didactics Case-based scenarios Video teaching resources Written materials Role play In-clinic teaching
Kripke et al.²⁴	Ambulatory	1 Day workshop	Didactics Video teaching resources Patient and expert panel discussion Role play
Loeb et al.²⁵	Ambulatory	3 Weeks	Didactics Case-based scenarios Role play
Powrie et al.²⁶	Inpatient	1 Month	Didactics Case-based scenarios Written materials
Rosen et al.²⁷	Not stated	1 Day workshop	Didactics Small group sessions Patient and expert panel discussion
Singh et al.²⁸	Ambulatory	1 Month	Didactics In-clinic teaching
Spagnoletti et al.²⁹	Elective online module	15 Weeks	Online module
Spencer and McNeil³⁰	Ambulatory	Not stated	Case-based scenarios (modified problem based learning)
Watkins and Moran³¹	Ambulatory	1 Day workshop	Didactics Video teaching resources Procedural training/hands-on skills

Table 3.

Frequency of Educational Methods in Included Curricula

Educational method	No. curricula (%)
Didactics	11 (69)
In-clinic teaching	7 (44)
Small group session/case-based scenarios	6 (38)
Video teaching resources	4 (25)
Written/printed/online material	4 (25)
Role play	4 (25)
Patient and/or expert panel discussion	2 (13)
Hands on session/procedural skills/simulation	2 (13)
Online module	1 (6)

Evaluation methods and quality

Learner assessment

Ten curricula used pre- and postintervention questionnaires to assess attitudes, knowledge, and/or behaviors of the learners.^{16

–19,22,24,26

–29} Two curricula utilized post-intervention only questionnaires.^20,21 Three studies utilized chart review to assess learner behavior.^25,28,31 All seven curricula that assessed attitudes showed an improvement in comfort or perceived preparedness in women's health topics post-intervention.^{16,18,20,24,27
–29} Similarly, all ten curricula that assessed knowledge showed improvement post-intervention,^{16

–19,22
–24,26,28,29} and seven showed statistically significant improvement.^{16
–18,22,24,28,29} Only three curricula (19%) specifically observed changes in learner behavior after curricular intervention: Loeb et al. showed a statistically significant improvement in documentation of sexual history in medical charts by residents²⁵; Singh et al. demonstrated an improvement in cervical cancer screening rates²⁸; Watkins and Moran found that residents were twice as likely to obtain an adequate pap smear.³¹ Learner assessment methods and outcomes are summarized in Table 4.

Table 4.

Summary of Learner Assessment Methods, Learner Outcomes, and Medical Education Research Study Quality Instrument Score

Author	Learner assessment methods	Learner outcomes	MERSQI score
Brienza et al.¹⁶	Randomized controlled trial Pre-test Post-test 6–12 months after	Attitudes: No difference in attitudes Knowledge: Statistically significant improvement in knowledge Behavior: No difference in skills or resource awareness	12.5
Ceylony et al.¹⁷	Single group Pre-test Post-test after rotation	Knowledge: Statistically significant improvement in knowledge	8
Conigliaro et al.¹⁸	Single group Pre-test during PGY-1 year Post-test during PGY-3 year Comparison of in-service examination scores Annual attitude survey	Attitudes: Increased comfort in discussing WH topics Knowledge: Statistically significant improvement in knowledge, improvement in in-service examination scores	12.5
Freda et al.¹⁹	Single group Pre-test Post-test	Knowledge: Knowledge gain observed (specific data not presented)	7
Haskell and Reisman²⁰	Single group Post-survey after a year	Attitudes: Residents perceived an improvement in their WH education	7
Henrich et al.²¹	Single group Post-survey	Data on learner attitudes, knowledge, and/or skills postintervention not reported	6.5
Jiang et al.²²	Single group Pre-test Post-test after rotation	Knowledge: Statistically significant improvement in knowledge	13
Korenstein et al.²³	Nonrandomized, 2 group Post-test 6–12 months after	Knowledge: Participants performed better on knowledge question compared to controls	11
Kripke et al.²⁴	Single group Pre-test Post-test post-workshop Post-test 6 months after	Attitudes: Statistically significant improvement in attitudes Knowledge: Statistically significant improvement in knowledge Behavior: Statistically significant improvement in skills immediately postworkshop but not maintained 6 months postworkshop, improvement in documentation of intimate partner violence inquiry	12.5
Loeb et al.²⁵	Single group Chart review 7 months pre- and post-intervention	Behavior: Statistically significant improvement in documentation of sexual history in medical charts by residents	12
Powrie et al.²⁶	Single group Pre-test Post-test after rotation	Knowledge: Improvement in knowledge (statistical significance not discussed)	10
Rosen et al.²⁷	Single group Pre-test Post-test post-workshop Post-test 6 months after	Attitudes: Increased comfort in discussing sexual history (statistical significance not discussed)	7
Singh et al.²⁸	Single group Pre-test Post-test after rotation Comparison of pap test orders pre- and post-intervention	Attitudes: Statistically significant improvement in comfort Knowledge: Statistically significant improvement in knowledge Behavior: Increase in cervical cancer screening rates	13
Spagnoletti et al.²⁹	Single group Pre-test Post-test after 6 months Pre- and post-module knowledge test	Attitudes: Statistically significant improvement in comfort and perceived preparedness Knowledge: Statistically significant improvement in knowledge	14
Spencer and McNeil³⁰	Single group Cross-sectional survey (informed development of curriculum)	Cross-sectional survey preintervention assessing learner comfort and knowledge in WH topics identified topics that informed development of the curriculum Data on attitudes, knowledge, and/or skills postintervention not reported	10
Watkins and Moran³¹	Randomized controlled trial Pre- and post-workshop evaluation of pap smear adequacy rates Immediate post-workshop survey	Behavior: Residents who received the intervention were more likely to obtain an adequate pap smear	16

MERSQI.¹⁴

MERSQI, Medical Education Research Study Quality Instrument; PGY, postgraduate year.

Curriculum evaluation

All 14 studies (88%) that performed curricular evaluation via survey and/or informal feedback demonstrated that the curricula were well received.^{16

–21,23,24,26

–31} Two curricula did not perform a formal program evaluation.^22,25

Quality

Total MERSQI scores ranged from 7 to 16. The average MERSQI score was 10.75. The median score was 11.5. Eleven studies scored 10 or higher.^{16,18,22

–26,28

–31} There were only two randomized controlled trials^16,31; the majority (63%) were single group pre-test post-test studies.^{17
–19,22,24

–29} Fifteen studies were conducted at a single institution.^{16

–21,23

–31} Validity evidence, including internal structure, content, and relationships to other variables, was generally poor. Data analysis was found to be appropriate in all included studies. The MERSQI scores are summarized in Table 4.

Discussion

In this scoping review, we described the landscape of women's health education in IM residency training. To our knowledge, this is the first review of women's health curricula specifically for IM residents. Despite efforts to improve women's health education in IM, there is still a limited amount of research being published on women's health education. We found only 16 published studies that met our inclusion criteria for this review. Surprisingly, the majority of the curricula included in this review were published before 2010. Based on a survey published in 2017 by Casas et al., 68% of surveyed program directors reported that their programs offered women's health electives, and 7% offered women's health concentrations or tracks.¹³ It is possible that IM residency programs have developed formal women's health curricula but have not published or disseminated their findings. We are also aware of asynchronous online ambulatory curricula, such as the Johns Hopkins Physician Education and Assessment Center modules,³² that contain modules on women's health topics. These modules have filled a need for teaching ambulatory topics in a standardized and easily accessible way. However, we did not find any published articles analyzing the impact of the women's health content of these online modules.

This review also revealed a general lack of interdisciplinary collaboration among published women's health curricula in IM residency programs. We found five curricula that incorporated other medical specialties such as Obstetrics and Gynecology,^{19,21,22,27,30} however, only one curriculum in this review involved another health profession (public health).²⁷ Although ultimately excluded, articles describing women's health curricula for medical students, nursing, and midwives were identified during our search. We believe that women's health education is an ideal topic for which to pursue interdisciplinary collaboration. Spencer and McNeil showed that an interdisciplinary curriculum created a community of practice and also maximized use of limited resources.³⁰ Henrich et al. found that an interdisciplinary women's health training model encouraged increased collaboration and learning, as well as further understanding of the interconnection of the disciplines in women's health.²¹ At a societal level, women are more likely to incur costly health care expenditures compared with men,³³ and are more engaged in health care decision-making.³⁴ The report published in 2013 by the U.S. HHS, HRSA, and OWH may provide a framework of how to incorporate interdisciplinary collaboration in women's health education,⁵ and address the increased demand for women's health care.

One significant barrier to implementing women's health curricula has been the lack of consensus regarding which women's health topics should be taught. There are discrepancies between ABIM's women's health core competencies,³ and the women's health topics listed in the ABIM certification examination blueprint, which are more specific.³⁵ These differences may lead to increased confusion about where to focus women's health training during residency. For this review, we based our definition of women's health topics on the expert consensus list of women's health topics for IM residents as published by Farkas et al. in 2017.⁶ The most common topics taught included intimate partner violence, menopause, abnormal uterine bleeding, breast and cervical cancer screening, and osteoporosis; however, these topics were each included in no more than 5 of the 16 curricula in this review. Our results revealed that there remains a lack of consensus regarding topics for women's health education in IM residency programs.

Our review also revealed that the teaching methods for women's health curricula are varied. The majority of the curricular interventions were incorporated into an established ambulatory curriculum. Only one curriculum was delivered in the inpatient setting. Three curricula were targeted at increasing exposure to women for residents in VA clinics. This deserves mentioning, as a study by Orsetti et al. revealed that residents working in a VA clinic reported less confidence in women's health topics compared to residents in a non-VA clinic.³⁶ Furthermore, we found that many curricula used more than one teaching method; didactics, in-clinic teaching, and small group/case-based scenarios were the most commonly used methods. Using mixed educational methods allows for better mastery and longer retention of women's health topics.³⁷ We advocate for designing curricula that include a combination of didactics, in-clinic teaching, and hands-on training to encourage more active, self-directed, and contextual women's health learning for IM residents.

The majority of curricula in this review assessed resident knowledge, comfort, and/or satisfaction, and it is encouraging that all showed improvement after the implementation of a women's health curriculum. Not only were these curricula well-received by residents but also were effective in improving resident knowledge in women's health topics. Only three curricula evaluated learner behavior, and we did not find any curricula evaluating patient outcomes. The quality of the studies included in this review is consistent with other published medical education studies. Reed et al. published a study in 2008 analyzing articles submitted to the medical education issue of the 2008 Journal of General Internal Medicine and found that the mean total MERSQI score of accepted articles was 10.7, compared with a mean total MERSQI score of 9 for rejected articles.³⁸ In comparison, the mean total MERSQI score of the studies included in this review was 10.75. This suggests that many curricula reviewed in this study utilized valid designs and incorporated rigorous evaluation methods.

More research is needed to inform how best to create, implement, and assess women's health curricular interventions. We believe that the expert consensus list of women's health topics by Farkas et al.⁶ is important groundwork for ultimately developing standardized core competencies for women's health curricula in IM residency. The development of core competencies would guide the development of curricular and assessment methods needed to successfully and broadly implement women's health teaching.³⁹ Based on our findings, we also believe that there is room for improvement in learner assessment, and we specifically encourage further research measuring the impact of women's health curricula on not only learner behavior but also patient outcomes.

There are several limitations to this study. It is possible that we may be missing potential eligible studies beyond the included databases. Our inclusion criteria, which defined a “curriculum” as containing formal educational strategies and evaluation methods, eliminated a number of articles that were purely descriptions of women's health educational interventions. Our goal, however, was to identify the highest quality educational interventions. Furthermore, we chose not to include articles describing women's health fellowships, as we wanted to focus on women's health curricula created for a broader audience. We also excluded curricula describing LGBT curricula for this review due to the fact that it is a mixed gender category. However, we are aware that there is significant overlap between LGBT health, women's health, and gender-specific care. We believe that LGBT health and gender-specific care are important content areas for residents that deserve further attention moving forward. Our focus for this review, however, was on curricula that focused on the care of women exclusively. Finally, the studies included in this review were heterogeneous in terms of content, delivery, evaluation, and quality, thereby limiting our ability to objectively compare and analyze the curricula. However, our approach provides a descriptive overview that should be helpful to medical educators and accrediting bodies.

Conclusion

This review summarizes published women's health curricula in IM residency. Despite national movements over the past two decades to expand women's health education, there is a limited amount of published articles describing women's health curricular interventions in IM residency, especially in the last decade. Based on our findings, we encourage IM residency programs to publish their women's health curricula to inform future improvements and advancements in women's health education. We also advocate for the establishment of formal core competencies in women's health by the ACGME to standardize women's health training across IM residencies and drive curricular and assessment efforts. Finally, we recommend increased interprofessional collaboration with other specialties and disciplines to improve women's health education, and ultimately, health care for women in this country.

Footnotes

Author Disclosure Statement

No competing financial interests exist.

Appendix Table A1. Search Strategy

Database	Search strategies
PubMed	((((“Women's Health”[Mesh] OR “Women's Health Services”[Mesh] OR “womens health”[tw] OR “Pelvic exam”[tw] OR “vaginal smears”[mh] OR “gynecological examination”[mh] OR “Pap smear”[tw] OR “papanicolaou test”[mh] OR “Cervical cancer screening”[tw] OR Contraception[tw] OR “Contraception”[mh] OR “Contraceptive counseling”[tw] OR “family planning services”[mh] OR Preconception[tw] OR “Preconception care”[mh] OR “Breast cancer screening”[tw] OR Menopause[tw] OR “menopause”[mh] OR “Hormone replacement therapy”[tw] OR “Hormone Replacement Therapy”[mh] OR “Sexually transmitted infection”[tw] OR “Sexually Transmitted Diseases”[mh] OR Vaginitis[tw] OR “Vaginitis”[mh] OR “Abnormal uterine bleeding”[tw] OR “Metrorrhagia”[mh] OR “Urinary incontinence”[tw] OR “Urinary Incontinence”[mh] OR Osteoporosis[tw] OR “Osteoporosis”[mh] OR “Osteoporosis, Postmenopausal”[mh] OR PCOS[tw] OR “Polycystic ovary syndrome”[tw] OR “Polycystic ovary syndrome”[mh] OR “Pregnancy counseling”[tw] OR Infertility[tw] OR “Infertility, Female”[mh] OR “Domestic violence”[tw] OR “domestic violence”[mh] OR “Intimate partner violence”[tw] OR “Intimate Partner Violence”[mh] OR “Eating disorders”[tw] OR “Feeding and Eating Disorders”[mh] OR “Lesbian health”[tw] OR “bisexual health”[tw] OR “Bisexuality”[mh] OR “Homosexuality, Female”[mh] OR “Sexual trauma”[tw] OR “rape”[mh] OR “breast health”[tw] OR “Gynecologic oncology”[tw] OR “Ovarian Neoplasms”[Mesh] OR “Ovarian cancer”[tw] OR “Uterine Neoplasms”[Mesh] OR “Uterine cancer”[tw] OR “Endometriosis”[Mesh] OR Endometriosis[tw] OR “Uterine fibroid”[tw] OR “Uterine fibroids”[tw] OR Fertility[tw] OR “fertility counseling”[tw] OR “Reproductive Health”[Mesh] OR “Reproductive health”[tw]))) AND ((“Internal Medicine/education”[Mesh] OR “Internship and Residency”[Mesh] OR “Education, Medical, Undergraduate”[Mesh] OR “Fellowships and Scholarships”[Mesh] OR “Students, Medical”[Mesh] OR “medical student”[tw] OR “medical students”[tw]))) AND ((“Program Evaluation”[Mesh] OR “Curriculum”[Mesh] OR curricul^*[tw] OR tracks[tw] OR “Women's health track”[tw])) • Search run December 2017 • Retrieved 441 articles
Embase	‘women's health’/exp OR ‘womens health services’:kw OR ‘womens health’:kw OR ‘pelvic exam’:kw OR ‘vaginal smear’:kw OR ‘gynecological examination’/exp OR ‘pap smear’:kw OR ‘cervical cancer prevention and control’/exp OR ‘cervical cancer screening’:kw OR ‘contraception’/exp OR contraception:kw OR ‘contraceptive counseling’/exp OR ‘contraceptive counseling’:kw OR ‘family planning’/exp OR ‘family planning services’:kw OR ‘prepregnancy care’/exp OR preconception:kw OR ‘breast cancer screening’:kw OR menopause:kw OR ‘menopause’/exp OR ‘hormone substitution’/exp OR ‘hormone replacement therapy’:kw OR ‘sexually transmitted disease’/exp OR ‘sexually transmitted infections’/exp OR ‘sexually transmitted infections’:kw OR ‘vaginitis’/exp OR vaginitis:kw OR ‘abnormal uterine bleeding’/exp OR ‘abnormal uterine bleeding’:kw OR ‘metrorrhagia’/exp OR ‘urine incontinence’/exp OR ‘urinary incontinence’:kw OR ‘osteoporosis’/exp OR osteoporosis:kw OR ‘ovary polycystic disease’/exp OR pcos:kw OR ‘polycystic ovary syndrome’:kw OR ‘pregnancy counseling’:kw OR ‘female infertility’/exp OR ‘female infertility’:kw OR ‘domestic violence’/exp OR ‘domestic violence’:kw OR ‘partner violence’/exp OR ‘intimate partner violence’:kw OR ‘eating disorder’/exp OR ‘eating disorders’:kw OR ‘lesbian health’:kw OR ‘bisexual health’:kw OR ‘homosexual female’/exp OR ‘bisexual female’/exp OR ‘sexual trauma’:kw OR ‘rape’/exp OR ‘breast health’:kw OR ‘gynecologic oncology’/exp OR ‘gynecologic oncology’:kw OR ‘ovary tumor’/exp OR ‘ovarian cancer’:kw OR ‘uterus cancer’/exp OR ‘uterine cancer’:kw OR ‘endometriosis’/exp OR endometriosis:kw OR ‘uterus myoma’/exp OR ‘uterine fibroids’:kw OR ‘female fertility’/exp OR ‘fertility counseling’:kw OR ‘reproductive health women’/exp OR ‘reproductive health’:kw AND (‘internal medicine’ NEAR/3 educat^):kw OR ‘medical education’/exp OR ‘undergraduate medical education’/exp OR ‘undergraduate medical education’:kw OR ‘medical student’/exp OR ‘medical students’:kw OR ‘fellowship’/exp OR ‘postgraduate fellowship’:kw AND program evaluation’/exp OR ‘curriculum’/exp OR curricul^:kw OR tracks:kw OR ‘womens health track’:kw • Search run February 2018 • Retrieved 536 articles
Scopus	(TITLE-ABS-KEY (“Women's Health” OR “Women's Health Services” OR “Pelvic exam” OR “vaginal smears” OR “gynecological examination” OR “Pap smear” OR “papanicolaou test” OR “Cervical cancer screening” OR contraception OR “Contraceptive counseling” OR “family planning services” OR preconception OR “Breast cancer screening” OR menopause OR “Hormone replacement therapy” OR “Sexually transmitted infection” OR “Sexually Transmitted Diseases” OR vaginitis OR “Abnormal uterine bleeding” OR metrorrhagia OR “Urinary incontinence” OR osteoporosis OR “Postmenopausal Osteoporosis” OR pcos OR “Polycystic ovary syndrome” OR “Pregnancy counseling” OR “Female Infertility” OR “Domestic violence” OR “Intimate partner violence” OR “Eating disorders” OR “Lesbian health” OR “bisexual health” OR “Sexual trauma” OR rape OR “breast health” OR “Gynecologic oncology” OR “Ovarian Neoplasms” OR “Ovarian cancer” OR “Uterine Neoplasms” OR “Uterine cancer” OR endometriosis OR “Uterine fibroid” OR fertility OR “fertility counseling” OR “Reproductive Health”)) AND ((TITLE-ABS-KEY (“Internal Medicine” W/3 education)) OR (TITLE-ABS-KEY ({Internship and Residency} OR “Undergraduate Medical Education” OR fellowships OR “medical students”))) AND (TITLE-ABS-KEY (“Program Evaluation” OR curriculum OR tracks OR “Women's health track”)) • Search run February 2018 • Retrieved 413 articles
Cochrane library	‘“Women's Health” OR “Women's Health Services” OR “Pelvic exam” OR “vaginal smears” OR “gynecological examination” OR “Pap smear” OR “papanicolaou test” OR “Cervical cancer screening” OR Contraception OR “Contraceptive counseling” OR “family planning services” OR Preconception OR “Breast cancer screening” OR Menopause OR “Hormone replacement therapy” OR “Sexually transmitted infection” OR “Sexually Transmitted Diseases” OR Vaginitis OR “Abnormal uterine bleeding” OR Metrorrhagia OR “Urinary incontinence” OR Osteoporosis OR “Postmenopausal Osteoporosis” OR PCOS OR “Polycystic ovary syndrome” OR “Pregnancy counseling” OR “Female Infertility” OR “Domestic violence” OR “Intimate partner violence” OR “Eating disorders” OR “Lesbian health” OR “bisexual health” OR “Sexual trauma” OR rape OR “breast health” OR “Gynecologic oncology” OR “Ovarian Neoplasms” OR “Ovarian cancer” OR “Uterine Neoplasms” OR “Uterine cancer” OR Endometriosis OR “Uterine fibroid” OR Fertility OR “fertility counseling” OR “Reproductive Health” AND “Internal Medicine education” OR “Internship and Residency” OR “Undergraduate Medical Education” OR Fellowships OR “medical students” AND Program Evaluation OR Curriculum OR tracks OR “Women's health track” in Title, Abstract, Keywords • Search run February 2018 • Retrieved 23 articles from Trials
ERIC	“Women's Health” OR “Women's Health Services” OR “Pelvic exam” OR “vaginal smears” OR “gynecological examination” OR “Pap smear” OR “papanicolaou test” OR “Cervical cancer screening” OR Contraception OR “Contraceptive counseling” OR “family planning services” OR Preconception OR “Breast cancer screening” OR Menopause OR “Hormone replacement therapy” OR “Sexually transmitted infection” OR “Sexually Transmitted Diseases” OR Vaginitis OR “Abnormal uterine bleeding” OR Metrorrhagia OR “Urinary incontinence” OR Osteoporosis OR “Postmenopausal Osteoporosis” OR PCOS OR “Polycystic ovary syndrome” OR “Pregnancy counseling” OR “Female Infertility” OR “Domestic violence” OR “Intimate partner violence” OR “Eating disorders” OR “Lesbian health” OR “bisexual health” OR “Sexual trauma” OR rape OR “breast health” OR “Gynecologic oncology” OR “Ovarian Neoplasms” OR “Ovarian cancer” OR “Uterine Neoplasms” OR “Uterine cancer” OR Endometriosis OR “Uterine fibroid” OR Fertility OR “fertility counseling” OR “Reproductive Health” AND (“internal medicine” AND educat^) OR (DE “Graduate Medical Education”) OR (DE “Medical Students”) OR “Internship and Residency” OR “Undergraduate Medical Education” OR Fellowships OR “medical students” AND (DE “Program Evaluation”) OR (DE “Curriculum” OR DE “Curriculum Development”) OR “Program Evaluation” OR Curricul^ OR track^* OR “Women's health track” • Search run February 2018 • Retrieved 12 articles
Web of science	TOPIC:(“Women's Health” OR “Women's Health Services” OR “Pelvic exam” OR “vaginal smears” OR “gynecological examination” OR “Pap smear” OR “papanicolaou test” OR “Cervical cancer screening” OR Contraception OR “Contraceptive counseling” OR “family planning services” OR Preconception OR “Breast cancer screening” OR Menopause OR “Hormone replacement therapy” OR “Sexually transmitted infection” OR “Sexually Transmitted Diseases” OR Vaginitis OR “Abnormal uterine bleeding” OR Metrorrhagia OR “Urinary incontinence” OR Osteoporosis OR “Postmenopausal Osteoporosis” OR PCOS OR “Polycystic ovary syndrome” OR “Pregnancy counseling” OR “Female Infertility” OR “Domestic violence” OR “Intimate partner violence” OR “Eating disorders” OR “Lesbian health” OR “bisexual health” OR “Sexual trauma” OR rape OR “breast health” OR “Gynecologic oncology” OR “Ovarian Neoplasms” OR “Ovarian cancer” OR “Uterine Neoplasms” OR “Uterine cancer” OR Endometriosis OR “Uterine fibroid” OR Fertility OR “fertility counseling” OR “Reproductive Health”) AND TOPIC: (“Internal Medicine education” OR “Internship and Residency” OR “Undergraduate Medical Education” OR Fellowships OR “medical students”) AND TOPIC:(“Program Evaluation” OR Curriculum OR tracks OR “Women's health track”) • Search run February 2018 • Retrieved 129 articles
MedEdPORTAL	(“Women's Health” OR “Women's Health Services” OR “Pelvic exam” OR “vaginal smears” OR “gynecological examination” OR “Pap smear” OR “papanicolaou test” OR “Cervical cancer screening” OR Contraception OR “Contraceptive counseling” OR “family planning services” OR Preconception OR “Breast cancer screening” OR Menopause OR “Hormone replacement therapy” OR “Sexually transmitted infection” OR “Sexually Transmitted Diseases” OR Vaginitis OR “Abnormal uterine bleeding” OR Metrorrhagia OR “Urinary incontinence” OR Osteoporosis OR “Postmenopausal Osteoporosis” OR PCOS OR “Polycystic ovary syndrome” OR “Pregnancy counseling” OR “Female Infertility” OR “Domestic violence” OR “Intimate partner violence” OR “Eating disorders” OR “Lesbian health” OR “bisexual health” OR “Sexual trauma” OR rape OR “breast health” OR “Gynecologic oncology” OR “Ovarian Neoplasms” OR “Ovarian cancer” OR “Uterine Neoplasms” OR “Uterine cancer” OR Endometriosis OR “Uterine fibroid” OR Fertility OR “fertility counseling” OR “Reproductive Health”) AND (“Internal Medicine education” OR “Internship and Residency” OR “Undergraduate Medical Education” OR Fellowships OR “medical students”) AND (“Program Evaluation” OR Curriculum OR tracks OR “Women's health track”) • Search run June 2018 • Retrieved 2 articles

ERIC, Education Resources Information Center.

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